Lifetime management for mitral valve disease: from current guidelines to new ones?

September 30, 2024

Prof. Martin Andreas

Mitral Highlights 2024

Prof. De Paulis

Aortic Highlights course, 2023

Prof. Borger

Aortic Highlights course, 2023

Prof. Michael Borger

MVT Intermediate 2022 Course

Prof. Siepe

Edwards Lifesciences at EACTS 2022: Aortic valve disease: Patient centric management in elderly population

Prof. Doenst

Edwards Lifesciences at EACTS 2022: State of the art in the treatment of aortic valve regurgitation in young patients

Prof. Augusto D’Onofrio

MVT Aortic 2022, vol.2

– What’s less invasive than minimally-invasive surgery? Micro-invasive.

– The initial pros and cons of each approach are clear, but what about the outcomes?

– Don’t forget to implement Enhanced Recovery After cardiac Surgery (ERAS) protocols.

Alexey Dashkevich

MVT Aortic 2022, Vol.2

– Is the patient 50-65 years old? Be sure to think about re-intervention, keep the guidelines in mind, and fully inform the patient.

– Which type of anticoagulation therapy should be used?

– Don’t forget, a Ross procedure may be an option.

Dr. Alisson Duncan

MVT Aortic 2022, vol.1

– PPM can be predicted and therefore, prevented

– How can we measure, normalize, and standardize various PPM-related assessments and risks?

– Make sure to consider the body surface area in relation to the transvalvular gradient, especially during physical activity or exercise

Prof. Alessandro Della Corte

MVT Aortic 2022, vol.1

– New classification system and nomenclature of bicuspid aortic valve (and bicuspid aortic valve disease)

– Genes are important, but a single gene may contribute to fewer than 1% of cases

– Different valve repair techniques according to valve phenotype

Dr. Mangino – MVT Intermediate 2021

Prof. Benussi – MVT Intermediate 2021

Prof. Kocher – EACTS 2021

The recently updated ESC/EACTS Guidelines contain two key changes in the recommendations for prosthetic valve selection:¹

A new Class IIb recommendation for bioprostheses in patients already on long-term NOACs
An upgraded Class I recommendation for bioprostheses in patients for whom good-quality anticoagulation is unlikely or contraindicated, and in patients whose life-expectancy is lower than the presumed durability of the valve

Importantly, the desire of the informed patient remains central to prosthetic valve selection. Valve durability in young patients is an important consideration, but long-term data on bioprosthetic SAVR have been limited.

INDURE registry

INDURE is a prospective, open-label, multicentre registry that is tackling this issue head-on. INDURE has enrolled over 400 patients aged up to 60 years who are undergoing SAVR with the INSPIRIS RESILIA valve in 21 sites across Europe and Canada. Patients are being followed up for five years, with echocardiograms analysed by Echo Core Laboratory at years one and five.^2,3

One-year results from the first 435 patients were reported at the 2021 EACTS Annual Meeting. Younger patients (up to 50 years old) in the registry were more likely to have a bicuspid aortic valve or aortic valve regurgitation at baseline than patients aged 51–60 years, but were less likely to have aortic stenosis, hypertension or diabetes.³

Excellent haemodynamic outcomes at 1 year

The excellent haemodynamic outcomes were comparable in the younger and older patient groups.

Plus, preliminary safety outcomes demonstrated low all-cause mortality and no confirmed cases of valve-related mortality up to one year. Rates of endocarditis and stroke were low (<1%). There were no cases of stage 3 SVD.

The INDURE registry will continue to provide clinical evidence on the use of the INSPIRIS RESILIA valve in young patients for the next 5 years.

Recommended resources

References

1. Vahanian A, Beyersdorf F, Praz F et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2021.

2. Meuris B, Borger MA, Bourguignon T et al. Durability of bioprosthetic aortic valves in patients under the age of 60 years – rationale and design of the international INDURE registry. J Cardiothorac Surg. 2020; 15: 119.

3. De Paulis R. Surgical aortic valve replacement in patients under 60 years old: A prospective, multicentre real-world registry in Europe and Canada. EACTS 2021.

For professional use. For a listing of indications, contraindications, precautions, warnings, and potential adverse events, please refer to the instructions for Use (consult eifi.edwards.com where applicable)

Edwards devices placed on the European market meeting the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC bear the CE marking of conformity.

Edwards, Edwards Lifesciences, the stylized E logo, INSPIRIS, and RESILIA are trademarks or service marks of Edwards Lifesciences Corporation or its affiliates. All other trademarks are the property of their respective owners.

Edwards Lifesciences • Route de l’Etraz 70, 1260 Nyon, Switzerland • edwards.com

Patients are at the core of the new ESC/EACTS guidelines. The recommendation for patient-focused decision making covers all therapeutic areas.

Key points include:

The patient-centred approach

Patient-centred decision making should be made by a fully collaborative Heart Team, right from clinical evaluation, imaging assessment through to intervention selection. Learn more about the importance of the Heart Team here.

All pieces of the puzzle need to fit together, to understand patient preferences and robustly diagnose and evaluate each patient, in order to come to a joint decision on treatment choice.

Prosthetic valve selection

To ensure the right treatment for each patient, every time, your patient should be given the opportunity to make an informed choice, and any decisions should be made in close collaboration with the Heart Team.

Involve your patients when it comes to:

- Understanding their lifestyle, any impact of anti-coagulation or the possibility of future re-do surgical, or transcatheter surgery
- Informing them of the influence of age in valve selection, particularly where life expectancy is less than bioprosthesis durability
- How valve selection will impact quality of life, whether this is an impact on diet or return to active lifestyle
- Understanding the potential risks and benefits of any potential intervention

The guidelines give a clear recommendation on when tissue valves should be selected, find out more here.

Edwards, Edwards Lifesciences, and the stylized E logo are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners.

Edwards Lifesciences • Route de l’Etraz 70, 1260 Nyon, Switzerland • edwards.com

Dr. Vinod Thourani