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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e112

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

Recommendation-Specific Supportive Text

1.	 Surgical repair of the aortic valve may be feasible in selected patients, depending on valve and aortic root anatomy and tissue characteristics. Published data suggest that valve repair can be performed safely and effectively by surgeons with training and experience in these techniques.1–3,7 However, given the complexities of patient selection and surgical techniques, such surgeries should be performed at a Comprehensive Valve Center. 2.	 Recent trials have demonstrated the benefits of TAVI in patients with severe, symptomatic AS. However, the early pivotal TAVI trials excluded patients with BAV. Initial studies using early-generation valves suggested a higher rate of paravalvular leak in the BAV population.4,5 Data from the STS/ ACC Transcatheter Valve Therapies Registry, which includes all consecutive TAVI procedures performed in the United States, suggest that with the use of newer-generation prosthetic valves the rate of paravalvular leak is no different in patients with a BAV than in patients with a trileaflet aortic valve. This registry also showed no difference in mortality rate at 30 days and 1 year between the BAV and tricuspid valve groups. However, the stroke rate at 30 days was higher in the BAV group.6 Other considerations are the younger age of patients with a BAV, for whom the risk–benefit ratio of TAVI versus SAVR needs careful consideration. RCTs are needed to obtain full clarity on the optimal use of TAVI in this population, as well as long-term outcomes.

6 MITRAL STENOSIS

The incidence of rheumatic MS is low in high-income countries and has been slowly declining in low- and middle-income countries, but MS remains a major cause of valve disease worldwide. Rheumatic MS is much more common in women (about 80% of cases) than in men. The clinical presentation of rheumatic MS varies, with patients from regions with a high disease prevalence presenting at a young age (teen years to age 30 years)

Figure 6. Intervention for replacement of the aorta in patients with a BAV. Colors correspond to Table 2. *Family history of aortic dissection, aortic growth rate ≥0.5 cm/y, and/or presence of aortic coarctation. BAV indicates bicuspid aortic valve; AVR, aortic valve replacement; and CVC, Comprehensive Valve Center.

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