Decision making in primary MR: which patient for which therapy
Dr. Dahle
Mitral Highlights course, 2023
Dr. Farber – MVT Intermediate 2021
Historically, survival data on patients with mild-to-moderate aortic stenosis (AS) have been limited. This situation was addressed in 2019, however, when Strange et al. published their analysis of the relationship between AS severity and mortality in a cohort of 241,303 adult patients in an observational registry. The mean age of patients at baseline was 61 years and median follow up was 1,208 days. Mild and moderate AS were found in 6.7% (n=16,129) and 1.4% (n=3,315) of patients, respectively.1
While it has been observed that severe AS is associated with poor survival, this study also suggests poor survival rates in patients with moderate AS. The five-year mortality rate for these patients was 56% (mean gradient 20.0–39.9 mmHg and/or peak velocity 3.0–3.9 m/s and/or aortic valve area greater than 1 cm²).
Mortality rates according to AS severity
The importance of early referral, regular clinical and echocardiographic surveillance and early intervention were emphasised in the recent update to the ESC/EACTS Guidelines for the management of valvular heart disease.2 In addition to recommendations for an active collaboration among Heart Team members and the inclusion of the informed patient’s preferences when determining optimal treatment, specific recommendations relevant to patients with moderate AS include:2
- Regular clinical and echocardiographic surveillance where prognosis of patients with normal-flow,
low-gradient AS and preserved ejection fraction is similar to that of moderate AS - Earlier referral if patient’s symptoms advance or worsen
- Earlier intervention to be considered in asymptomatic patients with:
- severe AS and left ventricular ejection fraction (LVEF) <55% without another cause (IIa)
- severe AS and a sustained fall in blood pressure (>20 mmHg) during exercise testing (IIa)
- LVEF >55% and a normal exercise test if the procedural risk is low and one of the following is present: very severe AS, severe valve calcification plus Vmax progression >0.3 m/s/year, or markedly elevated B-type natriuretic peptide levels without other explanation is present (IIa)2
The ESC/EACTS guidelines also support consideration of earlier intervention in select patients with asymptomatic aortic regurgitation.2
References
1. Strange G, Stewart S, Celermajer D et al. Poor long-term survival in patients with moderate aortic stenosis. JACC. 2019; 74: 1851–63.
2. Vahanian A, Beyersdorf F, Praz F et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021.
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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:
Informed patient choice is crucial
Patient life expectancy and quality of life should be considered
Patient-centred evaluation is at the heart of ensuring informed treatment choice is offered to patients
Prosthetic valve selection should be made during Heart Team evaluation, and with consideration of the patient’s preferences
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.
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Edwards Lifesciences • Route de l’Etraz 70, 1260 Nyon, Switzerland • edwards.com
Mr. Steve Livesey
Be courageous, be experienced, be ethical … according to the Guidelines!
The highly anticipated 2021 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for the management of valvular heart disease have finally landed.
We are excited to bring you a summary of the main updates, plus the new materials coming soon to support you and your teams in understanding and implementing the changes.
Key points include:
Treatment recommendations for all patients with severe aortic stenosis to be made by the Heart Team
Intervention options for patients with asymptomatic aortic stenosis
Bioprosthetic valves now recommended for those with life expectancy shorter than valve durability
Intervention recommended for patients with secondary mitral regurgitation, who remain symptomatic despite guideline-directed medical therapy
Use your experience of severe aortic stenosis to ensure the best patient outcomes
The choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) must be made following evaluation of all factors – clinical, anatomical and procedural – weighing the risks and benefits of each approach for all patients with severe aortic stenosis, and after discussion with the patient.
Treatment options have broadened for patients with asymptomatic aortic stenosis, including those with systolic left ventricular (LV) dysfunction (LV ejection fraction <55%) without another cause.
Enable more of your patients to live the active lifestyle they desire
Bioprosthetic valves now have a Class I recommendation for patients with life expectancy lower than the durability of the valve. Now, more of your patients can live a life free from anticoagulation. In addition, bioprosthetic valves may be considered for patients already on long-term novel oral anticoagulants.
Ensure you meet your patients’ high expectations by offering them the best valve technologies.
Be courageous, be experienced, be ethical… according to the guidelines!
Join us from the comfort of your office for a virtual symposium discussing the changes and what they mean for your practice. Eleven speakers from across Europe will cover the implications for the aortic, mitral and tricuspid valves. Click here for the full programme.
Tuesday 21 September 2021
3.00–7.45 pm CET
REGISTER NOW
Coming soon from Edwards
Edwards, Edwards Lifesciences, and the stylized E logo are trademarks or service marks of Edwards Lifesciences Corporation or its affiliates. All other trademarks are the property of their respective owners.
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Edwards Lifesciences • Route de l’Etraz 70, 1260 Nyon, Switzerland • edwards.com
Dr. Gianluigi Perri
MVT Aortic 2021
MVT Fundamentals Course
MVT Fundamentals Course
MVT Fundamentals Course
Michael Borger, Germany
Jean-Louis Vanoverschelde, Belgium
Can Gollmann-Tepeköylü, Austria
What to know in 2020
Introduction
With almost 380,000 deaths to date and just over 6 million confirmed cases, coronavirus disease 2019 (COVID-19) continues its global spread. In many countries, the first peak in cases has been reached or surpassed, and governments around the world are taking their first tentative steps towards easing lockdown restrictions as they attempt to find the difficult balance between public health and economic priorities.
The scientific effort to tackle the pandemic has brought new insights into the epidemiology and course of the disease, including several new reports detailing the link between COVID-19 and cardiac disease. Multiple studies have been initiated in the search for a vaccine and at least 15 clinical trials are already entering Phase I/II. Additionally, the antiviral remdesivir has become the first drug approved by the FDA for the treatment of COVID-19. Here, we summarise the latest use of cutting-edge science in the fight against COVID-19.
COVID-19 Strategies for impact reduction summary
For professional use.
Edwards Lifesciences, the stylized E logo, are trademarks of Edwards Lifesciences Corporation or its affiliates. All other trademarks or service marks are the property of their respective owners.
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Master of Valve Therapy – Nice, February 2019
