ESC Congress 2017 In Review -- Main Edition - 9

ESC Congress 2017

Table 6. Management of AF in Patients VHD
Recommendations

Class

Level

In Review

The indications for surgery in patients with asymptomatic aortic stenosis are shown in Table 8.
Table 8. Indications for Surgery in Asymptomatic Aortic Stenosis

Anticoagulation
NOACs should be considered as an alternative to VKAs
in patients with aortic stenosis, aortic regurgitation, and
mitral regurgitation presenting with AF.

2012
IIa

NOACs should be considered as an alternative to VKAs
after the third month of implantation in patients who
have AF associated with a surgical or transcatheter aortic valve bioprostheses.

IIa

The use of NOACs is not recommended in patients with AF
and moderate to severe mitral stenosis.

III

NOACs are contraindicated in patients with a mechanical
valve.

III

2017

IIb C Markedly elevated BNP levels.

IIa C Markedly elevated BNP levels
(> 3-fold age- and sex-corrected normal
range) confirmed by repeated measurements without other explanations.

IIb C Increase of mean pressure gradient with exercise by > 20 mm Hg.

Removed

IIb C Excessive LV hypertrophy in
the absence of hypertension.

Removed

2017 New Recommendation

IIa C Severe pulmonary hypertension (systolic pulmonary artery pressure at rest

Surgical Interventions

> 60 mm Hg confirmed by invasive measurement) without other explanation.

Surgical ablation of AF should be considered in patients
with symptomatic AF who undergo valve surgery.

IIa

Surgical ablation of AF may be considered in patients
with asymptomatic AF who undergo valve surgery, if feasible, with minimal risk.

IIb

The recommendations for choice of intervention in
symptomatic aortic stenosis are shown in Table 9.

Surgical excision or external clipping of the LA appendage
may be considered in patients undergoing valve surgery.

IIb

Table 9. Recommendations for Choice of Intervention in
Symptomatic Aortic Stenosis

AF, atrial fibrillation; LA, left atrial; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist.

Most of the recommendations for aortic regurgitation have remained the same as in the 2012 version. A
new recommendation on repairing valves states that
while most patients with aortic insufficiency will receive
a valve replacement, patients with tricuspid valve prolapse and an enlarged root should be considered for
aortic valve repair. The threshold for ascending aortic
replacement was lowered to an ascending aortic diameter of ≥ 45 mm in patients with a TGFBR1 or TGFBR2
mutations and to 40 mm in women with these mutations and low body surface area, patients with a TGFBR2
mutation, and patients with severe extra-aortic features.
The changes in recommendations for patients with
aortic stenosis are shown in Table 7.
Table 7. Changes in Recommendations for Aortic Stenosis
Changes in Recommendations
2012

2017

Indications for intervention in symptomatic aortic stenosis
IIb C Intervention may be
considered in symptomatic
patients with low-flow, lowgradient aortic stenosis and
reduced ejection fraction without flow (contractile) reserve.
CT, computed tomography.

IIa C Intervention should be considered
in symptomatic patients with low-flow,
low-gradient aortic stenosis and reduced
ejection fraction without flow (contractile)
reserve, particularly when CT calcium
scoring confirms severe aortic stenosis.

BNP, brain natriuretic peptide; LV, left ventricular.

Recommendations

Class

Level

Aortic valve interventions should only be performed in
centres with both departments of cardiology and cardiac
surgery onsite, and with structured collaboration between
the two, including a Heart Team (heart valve centres).

The choice of intervention must be based on careful individual evaluation of technical suitability and weighing of
risks and benefits of each modality. In addition, the local
expertise and outcomes data for the given intervention
must be taken into account.

SAVR is recommended in patients at low surgical risk (STS
or EuroSCORE II < 4% or logistic EuroSCORE I < 10% and
no other risk factors not included in these scores, such as
frailty, porcelain aorta, sequelae of chest radiation).

TAVI is recommended in patients who are not suitable for
SAVR as assessed by the Heart Team.

In patients who are at increased surgical risk (STS or
EuroSCORE II ≥ 4% or logistic EuroSCORE I ≥ 10% or
other risk factors not included in these scores such as
frailty, porcelain aorta, sequelae of chest radiation), the
decision between SAVR and TAVI should be made by the
Heart Team according to the individual patient characteristics, with TAVI being favoured in elderly patients
suitable for transfemoral access.

Balloon aortic valvotomy may be considered as a bridge
to SAVR or TAVI in haemodynamically unstable patients
or in patients with symptomatic severe aortic stenosis
who require urgent major noncardiac surgery.

IIb

Balloon aortic valvotomy may be considered as a diagnostic means in patients with severe aortic stenosis and
other potential cause for symptoms (ie, lung disease)
and in patients with severe myocardial dysfunction, prerenal insufficiency, or other organ dysfunction that may
be reversible with balloon aortic valvotomy when performed in centres that can escalate to TAVI.

IIb

SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons;
TAVI, transcatheter aortic valve implantation.
Tables 6-9 reprinted from Baumgartner H, Falk V et al. 2017 ESC/EACTS
Guidelines for the management of valvular heart disease. Eur Heart J. 2017.
doi:10.1093/eurheartj/ehx391. By permission of Oxford University Press on
behalf of the European Society of Cardiology.

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Congress 2017 In Review -- Main Edition