Valvular Heart Disease Guideline Comparison: Key Points
The following are key points to remember from a document comparing the American (ACC/AHA) and European (ESC/EACTS) guidelines for the management of valvular heart diseases:
- This review article, prepared on behalf of the EuroValve Consortium, highlights key differences between the 2020 American College of Cardiology/American Heart Association (ACC/AHA) and 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) valvular heart disease guidelines. Most discrepancies occur in areas with insufficient or conflicting data. The authors emphasize the need for continued randomized controlled trials and timely updates of the guidelines (every 5-6 years) based on rapidly evolving evidence.
- Severe aortic stenosis (AS): The ACC/AHA and ESC/EACTS guidelines largely concur on definitions of severe AS and on timing of intervention for aortic valve replacement (AVR). However, left ventricular ejection fraction (LVEF) cutoffs for intervention in asymptomatic patients with severe AS vary to some degree. Both guidelines state that LVEF <50% is a Class I indication for AVR. The ESC/EACTS guidelines state that LVEF <55% is a Class IIa indication for AVR, while the ACC/AHA guidelines state that LVEF <60% with longitudinal decrease in LVEF over 3 serial imaging studies is a Class IIb indication.
- Surgical AVR (SAVR) vs. transcatheter aortic valve implantation (TAVI) for severe AS: The ACC/AHA guidelines recommend SAVR in patients <65 years of age and with life expectancy >20 years, TAVI in those >80 years of age or with life expectancy <10 years (if femoral access route is feasible), and shared decision-making for patients 65-80 years of age. The ESC/EACTS guidelines recommend SAVR for patients <75 years of age with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM)/EuroScore <4, and TAVI for those >75 years of age or with STS-PROM/EuroScore >8 (and for nonoperative candidates).
- Severe chronic aortic regurgitation (AR): Both guidelines include a Class I recommendation for intervention in severe symptomatic AR. For asymptomatic patients, the ACC/AHA guidelines include a Class I indication for AVR in patients with LVEF ≤55%, while this is a Class IIb indication in the ESC/EACTS guidelines; both guidelines state that LVEF ≤50% is a Class I indication for AVR. Both guidelines recommend surgery for asymptomatic patients with severe AR and left ventricular end-systolic diameter (LVESD) >50 mm or >25 mm/m2(ACC/AHA guidelines, Class I; ESC/EACTS guidelines, Class IIa). The ACC/AHA guidelines state that TAVI is not recommended (Class III) in patients with isolated AR who are at low surgical risk.
- Severe chronic primary mitral regurgitation (MR): Both sets of guidelines include Class I recommendations for surgery for symptomatic patients and for patients with LVEF <60% and/or LVESD ≥40 mm. Mitral valve repair is generally preferred over mitral valve replacement. The documents both state that transcatheter edge-to-edge mitral valve repair (TEER) should be considered for symptomatic patients with primary MR only if the anatomy is favorable and if surgical risk is high or prohibitive (ACC/AHA guidelines, Class IIa; ESC/EACTS guidelines, Class IIb).
- Secondary mitral regurgitation (SMR): Both sets of guidelines emphasize the importance of guideline-directed medical therapy and heart team management in this situation. Notably, the ACC/AHA guidelines include no Class I recommendations for surgical or procedural intervention. The ESC/EACTS guidelines include a Class I recommendation for surgical intervention for severe SMR in patients undergoing coronary artery bypass grafting (CABG) or other cardiac surgery; this is a Class IIa recommendation in the ACC/AHA guidelines. Recommendations for TEER in severe symptomatic SMR differ considerably. The ACC/AHA guidelines emphasize favorable anatomy based on the COAPT trial (Class IIa recommendation for patients with LVEF 20-50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mm Hg). The ESC/EACTS guidelines take a more general approach and recommend considering TEER in patients who are not eligible for surgery and who are likely to respond to the treatment, taking both COAPT and MITRA-FR trial data into consideration (Class IIa recommendation). The ESC/EACTS guidelines also suggest TEER as an option for patients with advanced heart failure, provided that left ventricular assist device and heart transplant have also been considered (Class IIb recommendation), though they state that valve intervention is generally not an option for patients with LVEF <15%.
- Tricuspid regurgitation (TR): Both documents include a Class I recommendation for tricuspid valve surgery at the time of left-sided valve surgery in patients with severe TR. This is the only Class I recommendation for surgical intervention for TR in the ACC/AHA guidelines. The ESC/EACTS guidelines include a Class I recommendation for surgery in symptomatic patients with severe primary TR, provided that severe right ventricular dysfunction is not present. The ACC/AHA guidelines include a Class IIa recommendation for surgery for severe primary TR in patients with right heart failure. The ACC/AHA guidelines do not specifically address transcatheter tricuspid valve repair, while the ESC/EACTS guidelines provide a Class IIb recommendation for considering transcatheter repair in inoperable patients at heart valve centers with dedicated expertise.
- Prosthetic valves: Both sets of guidelines emphasize the importance of shared decision-making for valve selection, as well as lifelong follow-up after surgery. The ESC/EACTS guidelines recommend considering mechanical prostheses for the aortic position in patients <60 years of age, while the ACC/AHA guidelines recommend mechanical aortic prostheses for patients <50 years of age and either mechanical or bioprosthetic AVR in patients aged 50-65 years, based on shared decision-making and individual patient factors (all Class IIa recommendations). For the mitral position, both sets of guidelines recommend considering mechanical prostheses in patients <65 years of age (Class IIa recommendation).
