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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e85 CLINICAL STATEMENTS AND GUIDELINES

bleeding in the dabigatran group. Until there is an explanation of why these adverse events occurred, there is insufficient evidence to support the use of NOACs for patients with mechanical heart valves.7

2.5 Evaluation of Surgical and

Interventional Risk

Recommendation for Evaluation of Surgical and Interventional Risk

COR LOE Recommendation

1 C-EO 1.  For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using online tools when available, and discussed before the procedure as a part of a shared decision-making process.

Synopsis

Risk assessment has become a foundational element of the preprocedural evaluation of patients with VHD for whom intervention to correct the valve lesion may be contemplated. Although there are limitations to the scoring systems used to estimate the risk of adverse outcomes, these estimates provide a useful point of reference against which procedural benefits can be weighed. Numerical estimates of risk are just one component of the multidisciplinary team (MDT) assessment process, and factors not routinely included in risk algorithms (eg, liver disease, porcelain aorta) add important dimensions. The availability of TAVI for treatment of symptomatic severe aortic stenosis (AS) across the surgical risk spectrum emphasizes the need to have discussions about younger age at implantation, valve durability, and the potential need for permanent pacemaker implantation. For young patients (eg, <65 years of age) who opt for a surgical bioprosthesis, strategies for sequential procedures over a longer follow-up period (ie, valve-in-valve [ViV] TAVI versus reoperation) must be addressed.

Recommendation-Specific Supportive Text

1.	 The decision to intervene, as well as the type of procedure recommended, is based on an assessment of patient-, procedure-, and institution- or operator-specific short-term risks and long-term benefits (Table 8). Surgical mortality rate and major morbidity risks can be calculated with a webbased tool derived from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery database for 6 specific procedures (http://riskcalc.sts.org/ stswebriskcalc/calculate). TAVI-specific risk prediction tools are also available (http://tools.acc.org/ TAVRRisk/#!/content/evaluate/).1–6 Frailty assessment for at-risk patients is routine.7–11 Patients toward the higher end of the risk spectrum, for whom intervention would be futile or associated with a high likelihood of a poor outcome, should

Table 8.  Risk Assessment for Surgical Valve Procedures

Criteria Low-Risk SAVR (Must Meet ALL Criteria in This

Column) Low-Risk Surgical Mitral Valve Repair for Primary

MR (Must Meet ALL Criteria in This Column) High Surgical Risk (Any 1 Criterion in This

Column) Prohibitive Surgical Risk (Any 1

Criterion in This Column)

STS-predicted risk of death* <3%

AND <1%

AND >8%

OR Predicted risk of death or major morbidity

(all-cause) >50% at 30 d

OR

Frailty† None

AND None

AND ≤1 Indice (moderate to

severe)

OR ≥2 Indices (moderate to severe)

OR

Cardiac or other major organ system compromise not to be improved postoperatively‡ None

AND None

AND 1 to 2 Organ systems OR ≥3 Organ systems

OR

Procedure-specific impediment§ None None Possible procedure-specific

impediment Severe procedure-specific impediment

*Use of the STS Predicted Risk of Mortality (http://riskcalc.sts.org/stswebriskcalc/#/) to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of the STS average observed/expected mortality ratio for the procedure in question. The EUROSCORE II risk calculator may also be considered for use and is available at http://www.euroscore.org/calc.html. †Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) plus independence in ambulation (no walking aid or assistance required, or completion of a 5-m walk in <6 s). Other scoring systems can be applied to calculate no, mild, or moderate to severe frailty. ‡Examples of major organ system compromise include cardiac dysfunction (severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension); kidney dysfunction (chronic kidney disease, stage 3 or worse); pulmonary dysfunction (FEV1 <50% or DLCO2 <50% of predicted); central nervous system dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, cerebrovascular accident with persistent physical limitation); gastrointestinal dysfunction (Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0); cancer (active malignancy); and liver dysfunction (any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy). §Examples of procedure-specific impediments include presence of tracheostomy, heavily calcified (porcelain) ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, and radiation damage. DLCO2 indicates diffusion capacity for carbon dioxide; FEV1, forced expiratory volume in 1 s; INR, international normalized ratio; LV, left ventricular; MR, mitral regurgitation; RV, right ventricular; SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; and VKA, vitamin K antagonist.

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