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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 e139 CLINICAL STATEMENTS AND GUIDELINES

with a surgical aortic valve develop hemodynamic valve dysfunction at a median of 6.7 to 9.9 years after implantation.12 Patients typically remain asymptomatic until valve dysfunction is severe enough to result in adverse hemodynamic consequences or AF. Depending on the valve type and mechanism of regurgitation, some patients with asymptomatic, significant prosthetic valve regurgitation may require reintervention. For example, if prosthetic regurgitation is attributable to a bioprosthetic leaflet tear, more severe acute regurgitation may occur suddenly and cause clinical decompensation. With prosthetic valve stenosis, TTE diagnosis while the patient is asymptomatic alerts the clinician to the need for more frequent follow-up. A standardized definition and grading system for structural valve deterioration for surgical and transcatheter aortic valves have been proposed.13 In patients with mechanical valve prostheses, routine annual TTE evaluation is not needed if the postoperative baseline study is normal and no clinical change is apparent. Many of these patients require TTE studies for other indications, however, such as for the assessment of LV function, pulmonary artery pressure, or other cardiac or valve disease. 5.	 Durability data for bioprosthetic TAVI valves are less robust than the data for surgically implanted bioprosthetic valves. To date, the intermediateterm durability of TAVI valves has compared favorably with that of SAVR valves, as reported in randomized trials and registries.14–21 For the most part, these data reflect observations made in older patients and may not be applicable to younger populations (eg, <70 years). TAVI-based protocols typically include routine TTE before discharge and at 30 days and 1 year, in part because of reporting requirements. In the absence of clinical change, routine annual TTE studies are reasonable as experience continues to accumulate.

11.1.2 Selection of Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve

Recommendations for Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve Referenced studies that support the recommendations are summarized in Online Data Supplement 35. COR LOE Recommendations

1 C-LD 1.  For patients who require heart valve replacement, 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 valve replacement for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic valve is recommended.

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

2a B-NR 6.  For patients <65 years of age who have an indication for mitral valve replacement, do not have a contraindication to anticoagulation, and are unable to undergo mitral valve repair, it is reasonable to choose a mechanical mitral prosthesis over a bioprosthetic valve.1,7,10,11

2a B-NR 7.  For patients ≥65 years of age who require mitral valve replacement and are unable to undergo mitral valve repair, it is reasonable to choose a bioprosthesis over a mechanical valve.1,7,11

2b B-NR 8.  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.12–14

Synopsis

Shared decision-making about the choice of prosthetic valve type is influenced by several factors, including patient age, values, and preferences; expected bioprosthetic valve durability, avoidance of patient–prosthesis mismatch, and the potential need for and timing of reintervention; and the risks associated with long-term VKA anticoagulation after a mechanical valve replacement. (See also Section 3.2.4 regarding valve choice in patients with AS.) Despite the significantly higher rate of bioprosthetic structural valve deterioration observed in younger versus older patients,7–12,15 many younger patients choose to avoid a mechanical prosthesis because they are unwilling to consider long-term VKA therapy because of the inconvenience of monitoring, dietary restrictions, medication interactions, and the need to restrict participation in some types of athletic activity. A mechanical valve might be a prudent choice for patients for whom a second surgical procedure would be very high risk (eg, those with prior radiation exposure). The availability of TAVI has changed

Recommendations for Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve (Continued) COR LOE Recommendations

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