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What’s New in ACC/AHA Valve Guidelines 2014: Mitral Regurgitation A/Prof Yeo Khung Keong MBBS, ABIM Internal Medicine, Cardiology, Interventional Cardiology, ABVM Vascular Medicine,

What’s New in ACC/AHA Valve

Guidelines 2014:

Mitral Regurgitation

A/Prof Yeo Khung Keong

MBBS, ABIM (Internal Medicine, Cardiology, Interventional

Cardiology), ABVM (Vascular Medicine, Endovascular), FAMS, FACC,

Valve Guidelines

First guidelines in 1996 revised in 1998

2nd major revision 2006 with minor revision 2008 ESC guidelines 2013

Major changes

Stage system

• Reflects valve severity, effect on LV and symptoms

• Valve specific changes

• Adds the role of expertise and “Heart Valve Centre of Excellence”

Reviewers

2 official reviewers: ACC and the AHA

1 reviewer each from the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of

Cardiovascular Anesthesiologists, and STS

39 individual content reviewers (which included representatives from the

following ACC committees and councils: Adult Congenital and Pediatric

Cardiology Section, Association of International Governors, Council on Clinical Practice, Cardiovascular Section Leadership Council, Geriatric Cardiology

Section Leadership Council, Heart Failure and Transplant Council,

Interventional Council, Lifelong Learning Oversight Committee, Prevention of Cardiovascular Disease Committee, and Surgeon Council)

Approved for publication by ACC and AHA and endorsed by the AATS, ASE, SCAI, Society of Cardiovascular Anesthesiologists, and STS

Intervention

Indication for intervention is dependent on:

• Presence or absence of symptoms;

• The severity of VHD;

• Response of the LV and/or RV to the volume or pressure overload caused by VHD;

• The effect on the pulmonary or systemic circulation; and

• A change in heart rhythm

Stages

Heart Valve Team

• Management best achieved by a Heart Valve Team composed

primarily of a cardiologist and surgeon (including a structural valve interventionist if a catheter-based therapy is being considered)

• Multidisciplinary; including cardiologists, structural valve

interventionalists, cardiovascular imaging specialists, cardiovascular surgeons, anesthesiologists, and nurses

• Optimize patient selection through a comprehensive understanding

of the risk–benefit ratio of different treatment strategies

• Shared informed, decision-making approach with patient and family

Heart Valve Centres of Excellence

• Composed of experienced healthcare providers with expertise from multiple disciplines

• Offer all available options for diagnosis and management,

including complex valve repair, aortic surgery, and

transcatheter therapies

• Participate in regional or national outcome registries;

• Demonstrate adherence to national guidelines

• Participate in continued evaluation and quality improvement processes to enhance patient outcomes

• Publicly report their available mortality and success rates

Mitral Regurgitation

Secondary (Functional MR)

• Optimal medical tx first

• Biventricular pacing first if indicated

• MV surgery if going for cardiac surgery (eg CABG)

• Limited utility of surgery (IIB)

Optimal Timing of Intervention: Stage C

• Current approaches to identifying the optimal timing of

intervention in patients with progressive valve disease are

suboptimal

• Symptom onset is a subjective measure and may occur too late

in the disease course for optimal long-term outcomes

• Recommendations rely only on simple linear dimensions used in published series with data that may not reflect contemporary clinical outcomes

• However, LV enlargement and dysfunction are late

consequences of valve dysfunction

Better Options for Intervention: Stage D

• Moderate-to-severe VHD is present in 2.5% of the U.S

population a

• 4% and 9% of those 65 to 75 years of age

• 12% to 13% of those >75 years of age

• However, even with intervention, overall survival is lower than expected, and the risk of adverse outcomes due to VHD is

high, both because of limited options for restoring normal

valve function and failure to intervene at the optimal time

point in the disease course

Summary

• New staging system

• New valve criteria

• Symptoms

• Cardiac dysfunction

• Repair better than Replacement

• Heart valve surgery outcomes

• Percutaneous option for first time

• Heart teams and Heart valve centres of excellence