The “ten commandments” for the 2021 ESC/EACTS Guidelines on valvular heart disease

Abstract

Since the previous version of the guidelines on the management of patients with valvular heart disease (VHD), new data and experience have accumulated, making a revision of the document necessary. The 10 main messages of the new guidelines are: The incidence of degenerative aetiology continuously increases in industrialized countries and most affected patients are elderly with multiple comorbidities. At the same time, rheumatic heart disease is still frequent in other parts of the world. Emphasis is put on the importance of a patient-centred evaluation for intervention considering the expectations and values of the patient. The requirements for multidisciplinary Heart Valve Centre and heart valve clinics are described in the document (Figure 1) Echocardiography is the key technique to diagnose VHD and assess its severity and prognosis. Other non-invasive investigations such as cardiac computed tomography, cardiac magnetic resonance, and biomarkers play a more central role. New definitions of the severity of secondary mitral regurgitation are proposed based on the outcomes of randomized trials on intervention. For stroke prevention in patients with atrial fibrillation, the recommendation for non-vitamin K antagonist oral anticoagulants has been reinforced in patients with aortic stenosis and aortic and mitral regurgitation and those with surgical bioprostheses 3 months after implantation. Single antiplatelet therapy is recommended after transcatheter aortic valve implantation (TAVI) in patients without other indications for oral anticoagulants. Increasing surgical experience and safety support earlier intervention in asymptomatic patients at low risk with aortic stenosis and aortic or mitral regurgitation and those with tricuspid regurgitation. New information from randomized controlled trials comparing TAVI to surgery contributed to clarifying the role of each procedure in low-risk patients. Selection of the most appropriate mode of intervention (TAVI or surgery) by the Heart Team should consider the patient’s age, surgical risk, clinical and anatomical characteristics (particularly feasibility of the transfemoral access), local experience and outcome data, and importantly, informed patient preference. Transcatheter edge-to-edge repair (TEER) has been evaluated against optimal medical therapy in secondary mitral regurgitation resulting in an upgrade of the recommendation for patients fulfilling criteria suggesting an increased chance of responding to TEER. The larger number of studies on transcatheter valve-in-valve implantation after the failure of surgical bioprostheses led to upgrading its indications. Finally, encouraging preliminary experience suggests a potential role for transcatheter tricuspid valve intervention in inoperable symptomatic patients with severe tricuspid regurgitation. We wish the readers of the full guidelines in European Heart Journal a pleasant and enriching reading. Conflict of interest: none declared. Patient-centred evaluation for intervention. VHD, valvular heart disease; CCT, cardiac computed tomography; CMR, cardiac magnetic resonance; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography. Patient-centred evaluation for intervention. VHD, valvular heart disease; CCT, cardiac computed tomography; CMR, cardiac magnetic resonance; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography.

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