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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e88

CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Recommendation-Specific Supportive Text

1.	 The MDT is an established feature of heart valve programs20 and has been formally endorsed by the ACC, the American Society of Echocardiography, the Society for Cardiovascular Angiography and Interventions, the American Association for Thoracic Surgery, and the STS.12 Key members of the MDT include cardiologists with subspecialty expertise in the clinical evaluation of patients with VHD, as well as specialists in advanced cardiovascular imaging. For the evaluation of the patient with secondary mitral regurgitation (MR) and tricuspid regurgitation (TR), a specialist in HF also is included. Interventional cardiologists with training and expertise in VHD and surgeons experienced in the treatment of VHD anchor the MDT. Other team members include cardiovascular nurses, cardiovascular anesthesiologists, and intensivists involved in periprocedural care. Finally, the engagement of the primary clinical cardiologist and patient is of critical importance. The MDT facilitates presentation of all appropriate options for medical, interventional, and surgical treatment to the patient in a balanced manner, using tools and techniques for shared decision-making in which patient preferences are considered. 2.	 Decision-making is particularly challenging for the asymptomatic VHD patient, for whom the risks of operative mortality and perioperative morbidity must be very low and the chances of a successful and durable surgical outcome very high. There is a substantial body of literature to support a relationship between institutional volume and mortality rate for many cardiovascular procedures, including SAVR,1–5 TAVI,6 and surgical mitral valve repair.7–11 Consideration should be given to consultation with or referral to a Primary or Comprehensive Heart Valve Center for asymptomatic patients with severe VHD. Although excellent outcomes certainly can be achieved at lower-volume centers, assurance of outcomes equivalent to those of a higher-volume center is statistically more challenging.12 Similarly, for patients with multiple comorbidities for whom multispecialty collaboration is anticipated, care at a Comprehensive or Primary Valve Center ensures optimal outcomes. Although findings are mixed,13 there are data to support relationships between center volume and complication rates in cardiac surgical care,14 between center volume and failure to rescue after procedural complications,15–17 and between center volume and elements of infrastructure support.18,19

2.7 Management of Patients With VHD

After Valve Intervention

Interventions in patients with VHD include both transcatheter and surgical approaches. A valve intervention leaves the patient with either a prosthetic valve or a valve repair, often with an implanted device or other prosthetic material. Valve intervention does not eliminate valve disease; it replaces native valve disease with palliated valve disease. Patients with VHD continue to require periodic evaluation after intervention

Temporary mechanical support (including percutaneous support devices

such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO) Temporary mechanical support (including percutaneous support devices such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO) Left/right ventricular assist device capabilities (on-site or at an affiliated

institution) Cardiac catheterization laboratory, hybrid catheterization laboratory, or

hybrid OR laboratory§ Cardiac catheterization laboratory PPM and ICD implantation PPM and ICD implantation Criteria for institutional facilities and infrastructure IAC echocardiography laboratory accreditation IAC echocardiography laboratory accreditation 24/7 intensivist coverage for ICU *A primary (Level II) Center may provide additional procedures traditionally offered at a Comprehensive (Level I) Center as long as the criteria for competence and outcomes are met. †If intraoperative imaging and surgical expertise exist. ‡If mitral valve anatomy is not suitable for valve repair. §Equipped with a fixed radiographic imaging system and flat-panel fluoroscopy, offering catheterization laboratory-quality imaging and hemodynamic capability. AVR indicates aortic valve replacement; CT, computed tomography; ECMO, extracorporeal membrane oxygenation; ICD, implantable cardioverter defibrillator; IAC, Intersocietal Accreditation Commission; ICU, intensive care unit; MDT, multidisciplinary team; MR, mitral regurgitation; MRI, magnetic resonance imaging; OR operating room; PPM, permanent pacemaker; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation; TEE, transesophageal echocardiography; TEER, transcatheter edge-to-edge repair; TTE, transthoracic echocardiography; VHD, valvular heart disease; and ViV, valve-in-valve.

Used with permission from Nishimura et al.12

Table 11.  Continued

Comprehensive (Level I) Valve Center Primary (Level II) Valve Center

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