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

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e90

CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text

1.	 In patients who have had a valve intervention, most cardiologists continue to see patients for a clinical history and physical examination at annual intervals, or more frequently if needed for symptoms or concurrent conditions. A baseline TTE study is recommended after all valve interventions, including replacement with a prosthetic valve (see Section 11.1). This baseline postprocedural study ideally is performed 1 to 3 months after intervention to ensure loading conditions have returned to normal, but in some cases it may need to be done during the index hospitalization for the patient’s convenience. The timing of subsequent periodic imaging after valve intervention is based on the type of valve prosthesis or repair, length of time after valve intervention, residual valve dysfunction, ventricular size and systolic function, and any concurrent cardiac conditions (Table 12). TTE is the standard approach for periodic imaging, supplemented by TEE when prosthetic mitral valve dysfunction is a concern (see Section 11.1). Additional imaging with CT, fluoroscopy CMR, or PET is reserved for patients for whom there is concern about valve dysfunction (see Section 11.1) or endocarditis (see Section 12.1).1,2

3 AORTIC STENOSIS

3.1 Stages of Valvular AS

Medical and interventional approaches to the management of patients with valvular AS depend on accurate diagnosis of the cause and stage of the disease process. Table 13 shows the stages of AS, ranging from patients at risk of AS (Stage A) or with progressive hemodynamic obstruction (Stage B) to severe asymptomatic (Stage C) and symptomatic AS (Stage D). Each stage is defined by patient symptoms, valve anatomy, valve hemodynamics, and changes in the LV and vasculature. Hemodynamic severity is best characterized by the transaortic maximum velocity (or mean pressure gradient) when the transaortic volume flow rate is normal. Some patients with AS have a low transaortic volume flow rate that is either because of LV systolic dysfunction with a low LVEF or because of a small, hypertrophied LV with a low stroke volume. Severe AS with low flow is designated D2 (with a low LVEF) or D3 (with a normal LVEF). Meticulous attention to detail is required during assessment of aortic valve hemodynamics, either with Doppler echocardiography or cardiac catheterization, and the inherent variability of the measurements and calculations should always be considered in clinical decision-making. 3.2 Aortic Stenosis

3.2.1 Diagnosis and Follow-Up

3.2.1.1 Diagnostic Testing: Initial Diagnosis

Recommendations for Diagnostic Testing: Initial Diagnosis of AS Referenced studies that support the recommendations are summarized in Online Data Supplement 3. COR LOE Recommendations

1 A 1.   In patients with signs or symptoms of AS or a BAV, TTE is indicated for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention.1,2

1 B-NR 2.  In patients with suspected low-flow, lowgradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR.3–7

2a B-NR 3.  In patients with suspected low-flow, lowgradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve.8–10

2a B-NR 4.  In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity.1,11–13

2a B-NR 5.  In patients with suspected low-flow, lowgradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity.14–18

Synopsis

The overall approach to the initial diagnosis of VHD is discussed in Section 2.3, and additional considerations specific to patients with AS are addressed here.

Recommendation-Specific Supportive Text

1.	 In adult patients, physical examination may not be accurate for diagnosis of and assessment of severity of AS. Echocardiographic imaging allows reliable evaluation of valve anatomy and motion and the degree of valve obstruction. In addition, TTE is useful for measuring LV size and systolic function, identifying concurrent AR or MR, and estimating pulmonary systolic pressure.1,2,11,12,19–27 2.	 Measurements of AS severity made when the patient is hypertensive may underestimate or, less often, overestimate stenosis severity. Systemic hypertension imposes a second pressure load on the LV, in addition to valve obstruction, which

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