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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e86 CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease be identified.12–18 Risk prediction tools for transcatheter mitral valve repair are comparatively less robust.17–19 The relationship between operator/ institutional case volume and outcomes has been explored for surgical20 and transcatheter21–23 aortic valve replacement (AVR), surgical mitral valve repair and replacement,24–32 and transcatheter mitral valve repair.33 Table 9 includes examples of several factors that impact outcomes but are not routinely captured in currently available risk scores. Perioperative mortality rates for 6 specific surgical procedures are shown in Table 10. The potential to return to activities of daily living after an intervention must be considered. 2.6 The Multidisciplinary Heart Valve Team and Heart Valve Centers Recommendations for the Multidisciplinary Heart Valve Team and Heart Valve Centers COR LOE Recommendations 1 C-EO 1. Patients with severe VHD should be evaluated by a Multidisciplinary Heart Valve Team (MDT) when intervention is considered. 2a C-LD 2. Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable when treatment options are being discussed for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered.1–19 Synopsis The value of the MDT has become increasingly apparent as options in the treatment of VHD have broadened. Heart Valve Centers, in the context of an integrated multi-institutional model of care for patients with VHD, allow optimization of patient outcomes through improved decision-making and matching of patients to providers with appropriate expertise, experience, and resources.12 Primary and Comprehensive Heart Valve Centers are defined by their offerings and expertise in the management of patients with VHD12 (Table 11). Table 9. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores SAVR TAVI Surgical Mitral Valve Repair or Replacement TEER Technical or anatomic Prior mediastinal radiation Aorto-iliac occlusive disease precluding transfemoral approach Prior sternotomy Multivalve disease Ascending aortic calcification (porcelain aorta may be prohibitive) Aortic arch atherosclerosis (protuberant lesions) Severe MR or TR Low-lying coronary arteries Basal septal hypertrophy Valve morphology (eg, bicuspid or unicuspid valve) Extensive LV outflow tract calcification Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive) Valve morphology (eg, thickening, perforations, clefts, calcification, and stenosis) Prior mitral valve surgery Comorbidities Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty* Futility STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation *Validated frailty scores include the Katz Activities of Daily Living Score.10,34,35 COPD indicates chronic obstructive pulmonary disease; MR, mitral regurgitation; RV, right ventricular; SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation; TEER, transcatheter edge-to-edge repair; and TR, tricuspid regurgitation. Table 10. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019) Procedure Mortality Rate (%) AVR 2.2 AVR and CABG 4 AVR and mitral valve replacement 9 Mitral valve replacement 5 Mitral valve replacement and CABG 9 Mitral valve repair 1 Mitral valve repair and CABG 5 AVR indicates aortic valve replacement; CABG, coronary artery bypass graft surgery; and STS, Society of Thoracic Surgeons. Downloaded from http://ahajournals.org by on October 7, 2026