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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 e97 CLINICAL STATEMENTS AND GUIDELINES

hazard ratio for a BNP level >300 pg/mL (3 times normal) of 7.38 (CI: 3.21 to 16.9).32 Serum BNP levels also are predictive of symptom onset during follow-up and persistent symptoms after AVR.36 9.	 Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS once the aortic velocity reaches ≥2 m/s. Although the average rate of hemodynamic progression for calcific stenosis of a trileaflet valve is an increase in aortic velocity of about 0.3 m/s per year, an increase in mean gradient of 7 to 8 mm Hg per year, and a decrease in valve area of 0.15 cm2 per year, there is marked variability between patients in disease progression. Predictors of rapid disease progression include older age, more severe valve calcification, and a faster rate of hemodynamic progression on serial studies. In patients with an aortic velocity >4 m/s in addition to predictors of rapid disease progression, symptom onset is likely in the near future, so there is less benefit to waiting for symptom onset. Thus, elective AVR may be considered if the surgical risk is low and after consideration of other clinical factors and patient preferences. 10.	  In adults with initially asymptomatic severe AS, the rate of sudden death is low (<1% per year). However, an aortic velocity ≥5 m/s or an LVEF <60% each is associated with higher all-cause and cardiovascular mortality rates in the absence of AVR.31 A multivariate analysis of predictors of death in a large cohort (>500 patients) showed a >4-fold higher risk of cardiovascular death for those with an LVEF <60% than for those with a higher LVEF (HR: 4.47; 95% CI: 2.06 to 9.70).33 A progressive decrease in LVEF is most likely in those with an LVEF <60% before AS becomes severe.8,9,11 Evaluation for other causes of a decline in LVEF is appropriate, particularly when AS is not yet severe, but a progressive decline in LV systolic function is of concern and should prompt more frequent evaluation; and consideration of AVR when repeat studies show a progressive decline in LVEF without other cause with a lack of response to medical therapy. The presence of at least 3 serial imaging studies showing a consistent decline in LVEF ensures that the changes seen are not simply attributable to recording, measurement, or physiological variability.8–11 11.	  Hemodynamic progression eventually leading to symptom onset occurs in nearly all asymptomatic patients with AS. The survival rate during the asymptomatic phase is similar to age-matched controls, with a low risk of sudden death (<1% per year) when patients are followed prospectively and when patients promptly report symptom onset. The rate of symptom onset is strongly dependent on the severity of AS, with an eventfree survival rate of about 75% to 80% at 2 years in those with a jet velocity <3.0 m/s, compared with only 30% to 50% in those with a jet velocity ≥4.0 m/s. Patients with asymptomatic AS require periodic monitoring for development of symptoms and progressive disease (Section 3.1). In patients with moderate calcific AS undergoing cardiac surgery for other indications, the risk of progressive VHD is balanced against the risk of repeat surgery or TAVI (Sections 4.3.3 and 10). This decision must be individualized on the basis of the specific operative risk in each patient, clinical factors such as age and comorbid conditions, valve durability, and patient preferences.13,49,62–64

3.2.4 Choice of Intervention

3.2.4.1 Choice of Mechanical Versus Bioprosthetic AVR

Recommendations for Choice of Mechanical Versus Bioprosthetic AVR Referenced studies that support the recommendations are summarized in Online Data Supplements 11 and 12.

COR LOE Recommendations

1 C-EO 1.  In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.

1 C-EO 2.  For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.

2a B-R 3.  For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.1

2a B-NR 4.  For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.1–10

2a B-R 5.  In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.1

2b B-NR 6.  In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.11–13

Synopsis

Shared decision-making about the choice of prosthetic valve type is influenced by several factors,

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