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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 e89 CLINICAL STATEMENTS AND GUIDELINES

for early postprocedural issues, long-term medical therapy, monitoring of the prosthetic valve or repair, management of concurrent cardiac conditions, and persistent symptoms or functional limitation. Endocarditis prophylaxis is discussed in Section 2.4.2; antithrombotic therapy for prosthetic valves in Sections 11.2 to 11.5; and prosthetic valve complications, including valve thrombosis, stenosis, or regurgitation, in Sections 11.6 to 11.8.

2.7.1 Procedural Complications

The most common complication early after surgical valve replacement is postoperative AF, which occurs in up to one-third of patients within 3 months of surgery (see Sections 2.4.3 and 14.1). Other complications include stroke, vascular and bleeding complications, pericarditis, heart block requiring temporary or permanent pacing (especially after AVR), HF, renal dysfunction, and infection. Complications after transcatheter interventions depend on the specific procedure but can include the need for permanent pacing, paravalvular leak, stroke, vascular complications, and residual valve dysfunction. 2.7.2. Primary and Secondary Risk Factor Evaluation and Treatment Concurrent coronary artery disease (CAD) is common in adults with VHD. Management of CAD at the time of valve intervention is discussed in Section 14.2. After valve intervention, evaluate and treat patients with CAD risk factors according to current guidelines for primary and secondary prevention. Although there is no convincing evidence that treating CAD risk factors will reduce the likelihood of progressive valve dysfunction after intervention, cardiovascular outcomes are improved overall because of a reduced rate of coronary events. 2.7.3. Persistent Symptoms After Valve Intervention Persistent symptoms occur in many patients after valve intervention. The first step in evaluation is to assess valve function to ensure symptoms are not caused by persistent or recurrent stenosis, regurgitation, or a valve complication. The next step is to evaluate and treat any concurrent cardiac disease and noncardiac conditions that may be the cause of symptoms. Symptoms also may be attributable to irreversible consequences of valve disease, including LV systolic and diastolic dysfunction, pulmonary hypertension, and RV dysfunction. Treatment of symptoms for these patients is based on GDMT for HF and/or pulmonary hypertension.

2.7.4 Periodic Imaging After Valve Intervention

Recommendation for Periodic Imaging After Valve Intervention COR LOE Recommendation

1 C-EO 1.  In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.

Synopsis

A TTE is useful after either catheter-based or surgical intervention to provide a baseline measurement of valve function and the status of the ventricle. Repeat TTE is recommended with either new symptoms or a change in the physical examination. The timing of periodic follow-up imaging is based on the type of valve intervention.

Table 12.  Timing of Periodic Imaging After Valve Intervention

Valve Intervention Imaging Follow-Up*

Minimal Imaging Frequency† Location

Mechanical valve (surgical) Baseline Primary Valve Center Bioprosthetic valve (surgical) Baseline, 5 and 10 y after surgery,‡ and then annually Primary Valve Center Bioprosthetic valve (transcatheter) Baseline and then annually Primary Valve Center Mitral valve repair (surgical) Baseline, 1 y, and then every 2 to 3 y Primary Valve Center Mitral valve repair (transcatheter) Baseline and then annually Comprehensive Valve Center Bicuspid aortic valve disease Continued post-AVR monitoring of aortic size if aortic diameter is ≥4.0 cm at time of AVR, as detailed in Section 5.1 Primary Valve Center *Initial postprocedural TTE is recommended for all patients, ideally 1 to 3 months after the procedure. Annual clinical follow-up is recommended annually for all patients after valve intervention at a Primary or Comprehensive Valve Center. †Repeat imaging is appropriate at shorter follow-up intervals for changing signs or symptoms, during pregnancy, and to monitor residual or concurrent cardiac dysfunction. ‡Imaging may be done more frequently in patients with bioprosthetic surgical valves if there are risk factors for early valve degeneration (eg, younger age, renal failure, diabetes).

AVR indicates aortic valve replacement; and TTE, transthoracic echocardiography.

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