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2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Prosthetic Valve Stenosis

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis.	2014 recommendation remains current.
IIa	C-LD	In patients with suspected or confirmed bioprosthetic valve thrombosis who are hemodynamically stable and have no contraindications to anticoagulation, initial treatment with a VKA is reasonable.	NEW: Case series of patients presenting with bioprosthetic valve stenosis have suggested improvement in hemodynamics with VKA treatment because of resolution of thrombus on the valve leaflets.
IIa	B-NR	For severely symptomatic patients with bioprosthetic aortic valve stenosis judged by the heart team to be at high or prohibitive risk of reoperation, and in whom improvement in hemodynamics is anticipated, a transcatheter valve-in-valve procedure is reasonable.	NEW: Registries and case series have reported on the short-term outcomes and complication rates in patients with bioprosthetic AS who have undergone transcatheter valve-in-valve therapy.

Recommendations for Prosthetic Valve Regurgitation

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation.	2014 recommendation remains current.
IIa	C-LD	Surgery is reasonable for asymptomatic patients with severe bioprosthetic regurgitation if operative risk is acceptable.	MODIFIED: LOE updated from C to C-LD. A specific indication for surgery is the presence of severe bioprosthetic regurgitation in a patient with acceptable operative risk. With the new recommendation for valve-in-valve therapy, indications for intervention need to account for patients who would benefit from surgery versus those who would benefit from transcatheter therapy, determined by type of valve, symptomatic status, and risk of reoperation.
IIa	C-LD	Surgery is reasonable for asymptomatic patients with severe bioprosthetic regurgitation if operative risk is acceptable.	MODIFIED: LOE updated from C to C-LD. A specific indication for surgery is the presence of severe bioprosthetic regurgitation in a patient with acceptable operative risk. With the new recommendation for valve-in-valve therapy, indications for intervention need to account for patients who would benefit from surgery versus those who would benefit from transcatheter therapy, determined by type of valve, symptomatic status, and risk of reoperation.
IIa	B	Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure	2014 recommendation remains current.
IIa	B-NR	For severely symptomatic patients with bioprosthetic aortic valve regurgitation judged by the heart team to be at high or prohibitive risk for surgical therapy, in whom improvement in hemodynamics is anticipated, a transcatheter valve-in-valve procedure is reasonable.	NEW: Registries and case series of patients have reported on the short-term outcomes and complication rates for patients with bioprosthetic aortic regurgitation who have undergone transcatheter valve-in-valve replacement.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

New Recommendations

Recommendations	Class	Level
I	C	Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
IIa	B-NR	Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
IIa	C	Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Infective Endocarditis Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy.	2014 recommendation remains current.
I	C	Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.	2014 recommendation remains current.
I	B	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.	2014 recommendation remains current.
IIa	B	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection.	2014 recommendation remains current.
IIa	C	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE.	2014 recommendation remains current.
IIa	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.	2014 recommendation remains current.
IIb	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon).	2014 recommendation remains current.
IIb	B-NR	Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage.	NEW: The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
IIb	B-NR	Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable.	NEW: In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

Management of Coronary Artery Disease (CAD) in patients with Valvular Heart Disease (VHD)

Recommendations	Class	Level
Diagnosis of Coronary Artery Disease
Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: • history of cardiovascular disease • suspected myocardial ischaemiad • LV systolic dysfunction • in men >40 years of age and postmenopausal women • one or more cardiovascular risk factors.	I	C
Coronary angiography is recommended in the evaluation of moderate to severe secondary mitral regurgitation.	I	C
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk.	II	A
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk.	IIa	C
Indications for Myocardial Revascularization
CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥70%	I	C
CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥50–70%.	IIa	C
PCI should be considered in patients with a primary indication to undergo TAVI and coronary artery diameter stenosis >70% in proximal segments.	IIa	C
PCI should be considered in patients with a primary indication to undergo transcatheter mitral valve interventions and coronary artery diameter stenosis >70% in proximal segments.	IIa	C
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CT = computed tomography; LV = left ventricular; MSCT = multislice computed tomography; PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease.