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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 e138

CLINICAL STATEMENTS AND GUIDELINES Synopsis

The clinical course of patients with prosthetic heart valves or repaired native valves is influenced by several factors, including ventricular function, AF, pulmonary hypertension, and CAD, as well as by the development of valve-related complications. The interval between routine follow-up visits depends on the patient’s valve type, the presence of residual heart disease, and other clinical factors. Attention to optimal dental care and endocarditis prophylaxis and any needed anticoagulation is a requisite component of care. TTE is the primary imaging modality for postoperative assessment of prosthetic valve or repaired native valve function. In the absence of early complications, the index study is performed during hospitalization or within the first several weeks thereafter, depending on individual patient circumstances and the type of valve procedure. Additional imaging, such as TEE, cardiac CT, or fluoroscopy, may be required when valve dysfunction is suspected and in the context of the clinical presentation. A schedule for surveillance TTE studies has become an established feature of long-term follow-up, although the frequency of routine studies that are performed in the absence of clinical change will vary as a function of valve type.

Recommendation-Specific Supportive Text

1.	 TTE after valve implantation or repair provides an assessment of the procedural results and serves as a baseline against which comparison can be made for any change. TTE provides accurate measurements of transvalvular velocities and pressure gradients, as well as detection and quantitation of transvalvular and paravalvular leak.1–4 Normal transvalvular velocities and gradients vary across different types and sizes of prosthetic valves but are also affected by patient-specific factors, including body size and cardiac output. The postoperative study, recorded when the patient is asymptomatic and in a stable hemodynamic state, provides Doppler flow data for a specific valve in an individual patient. In addition, TTE provides assessment of other valve disease(s), pulmonary artery pressure, atrial size, LV and RV size and function, and pericardial disease. 2.	 Bioprosthetic or repaired native valve dysfunction typically presents with the insidious onset of HF symptoms or a change in the auscultatory findings. More abrupt and severe symptoms may occur with infective endocarditis or rupture of a valve cusp. Patients with mechanical valve dysfunction may present with HF, shock, thromboembolic events, hemolysis, or a change in auscultatory findings. Presentation may often be acute or subacute because of thrombus formation and more abrupt impairment of leaflet opening or closure. Attention should be directed to the trend in recent INR determinations. Prosthesis– patient mismatch and functional stenosis of a repaired native valve are also to be considered in the evaluation of patients with HF symptoms. Repeat noninvasive assessment begins with transthoracic echocardiography, comparison with the index postoperative study when available, and the use of other modalities as dictated by the clinical context and preliminary findings. 3.	 TTE is the preferred approach for initial assessment of suspected prosthetic valve dysfunction because it allows for measurement of transvalvular velocity, gradient, and valve area. TTE also allows quantitation of LV volumes and LVEF, an estimate of pulmonary artery systolic pressure, and evaluation of right heart function. However, the LA side of a prosthetic mitral valve is obscured by acoustic shadowing from the TTE approach, resulting in reduced sensitivity for detection of prosthetic MR and prosthetic mitral valve thrombus, pannus, or vegetation. TEE provides superior imaging of the LA side of the mitral prosthesis and is accurate for diagnosis of prosthetic mitral valve dysfunction.5,6 Both TTE and TEE are also needed for patients with prosthetic aortic valves in whom the posterior aspect of the valve is shadowed on the TTE approach and the anterior aspect of the valve is shadowed on the TEE approach.7,8 TEE has superior sensitivity for the detection of vegetations and abscess formation in patients with suspected prosthetic valve (or annuloplasty ring) endocarditis. With mechanical valve obstruction, fluoroscopy or CT imaging can also be helpful for detection of reduced motion caused by pannus ingrowth or thrombus. 4.	 Studies based on TTE follow-up estimate that approximately 30% of patients with a surgical aortic valve bioprosthesis develop evidence of valve dysfunction over the 10 years after implantation (defined as an increase in mean gradient of ≥10 mm Hg or a worsening of transprosthetic regurgitation from mild to moderate or from moderate to severe).9 The incidence of clinically important structural valve deterioration increases markedly more than 10 years after surgery, such that routine annual TTE studies thereafter are reasonable.10,11 Risk factors associated with accelerated (<5 years) valve deterioration include young age (<60 years) at implantation, smoking, diabetes mellitus, chronic kidney disease, initial mean gradient ≥15 mm Hg, and valve type.9,12 The selective adoption of an earlier, annual TTE screening program may be considered for at-risk patients on an individual basis, as up to 13% of patients

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