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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 e155 CLINICAL STATEMENTS AND GUIDELINES

repeat AVR. Although surgical reoperation is associated with acceptable mortality and morbidity rates in the current era, it still carries a higher risk than the initial surgery. Kaneko and colleagues examined a cohort of 3380 patients from the STS database (2011–2013) who underwent elective isolated reoperative AVR, and they demonstrated a higher (but acceptable) operative mortality rate than that seen with initial AVR (4.6% versus 2.2%; P<0.0001) and relatively low complication rates.13 This was true even among octogenarians who underwent reoperative AVR.3 In a cohort of 136 consecutive patients who underwent surgical correction for a non–endocarditis-related aortic or mitral paravalvular leak (1986–2001), surgical correction of the paravalvular leak was associated with acceptable operative mortality (6.6%) and morbidity rates.1 More recently, Shah and colleagues reported an operative mortality rate of 3% among 495 patients undergoing surgery for paravalvular leak,14 with higher risk associated with mitral than with aortic valve procedures (odds ratio: 1.66; 95% CI: 1.25–2.20). These findings are consistent with the findings of Bouhout and colleagues,15 who reported operative mortality rates of 8% among mitral valve, 3% among aortic valve, and 14% among double-valve patients in a total cohort of 190 patients undergoing surgery indicated for paravalvular leak. Estimates of operative risk for individual patients can be calculated by using the STS risk calculator (http://riskcalc.sts.org/stswebriskcalc/).16 2.	 Prosthetic valve deterioration can result in regurgitation attributable to leaflet calcification and noncoaptation or leaflet degeneration with a tear or perforation. Even in asymptomatic patients with severe prosthetic regurgitation, valve replacement is reasonable because of the risk of sudden clinical deterioration if further leaflet tearing occurs. IE should be excluded or concurrently treated. If a “watchful waiting” approach is taken in asymptomatic patients with severe prosthetic valve regurgitation, referral to a Comprehensive Heart Valve Center is prudent. 3.	 In some patients, operative risk is high, or surgery is not feasible. Nonrandomized studies have demonstrated clinical success with percutaneous paravalvular leak closure performed by expert operators under the supervision of an MDT at a Comprehensive Valve Center. Procedural success rates for percutaneous paravalvular leak closure, typically defined by no more than mild residual regurgitation and the absence of death and major complications, are highly variable. In a large single-center cohort, percutaneous repair of 141 paravalvular defects was attempted in 115 patients, with an achieved overall success rate of 77% and a 30-day complication rate of 8.7%.6 In another study of 126 patients who underwent percutaneous paravalvular leak repair, Sorajja and colleagues reported a 3-year survival rate of 64.3%.5 The degree of residual regurgitation affects symptom improvement and survival. In a cohort of 231 consecutive patients (2006–2017) who underwent percutaneous mitral paravalvular leak closure, the reduction of paravalvular leak to mild or less was achieved in 70% of patients.7,8 Those patients with mild or less residual paravalvular leak had a survival rate at 3 years of 61%, compared with a rate of 47% in patients with greater degrees of residual paravalvular leak (P=0.002).7,8 Notably, treatment of HF symptoms with paravalvular leak closure is more successful than is treatment of hemolysis. IE should be excluded before attempted paravalvular leak repair. 4.	 The Valve-In-Valve International Data registry examined outcomes of transcatheter ViV procedures in 459 patients, of whom about 30% had isolated regurgitation and 30% had mixed lesions.10 Within 1 month after the ViV procedure, 7.6% of patients died, 1.7% had a major stroke, and 93% of survivors experienced good functional status. The 1-year survival rate was 83.2%.10 Several systematic reviews have compared outcomes of transcatheter ViV with those of reoperative SAVR. In 1 report, ViV had similar hemodynamic outcomes to repeat surgery and lower stroke risk and bleeding risk than repeat surgery.11 A meta-analysis of 498 patients demonstrated no significant differences in early and mid-term all-cause mortality rates with ViV or reoperation.17 In another meta-analysis of 342 patients, reoperative AVR was compared with transcatheter ViV for failed degenerated aortic bioprosthesis and the group undergoing reoperative AVR had a lower all cause mortality with superior hemodynamic outcomes.18 Thus, although transcatheter ViV appears to be a safe and feasible alternative to repeat SAVR in patients who are inoperable or at high surgical risk, repeat SAVR should remain the standard of care, particularly in low-risk patients.18

12 INFECTIVE ENDOCARDITIS

12.1 Classification of Endocarditis

Endocarditis is classified according to whether a native or prosthetic valve is affected and by timing of infection after valve intervention. Prevention of endocarditis is important in all patients with valve disease, both before and after valve replacement or intervention (see Section 2.4.2). The risk factors involved with IE and the predominating causative organisms have evolved over

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