#valvular-heart-disease #guideline #aortic-stenosis #prosthetic-valves #TAVI

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease

Authors, Journal, Affiliations, Type, DOI

Authors: Catherine M. Otto, Rick A. Nishimura (Co-Chairs), Robert O. Bonow, Blase A. Carabello, John P. Erwin III, Federico Gentile, Hani Jneid, Eric V. Krieger, Michael Mack, Christopher McLeod, Patrick T. O'Gara, Vera H. Rigolin, Thoralf M. Sundt III, Annemarie Thompson, Christopher Toly
Journal: Circulation, 2021;143:e72–e227
Affiliations: ACC/AHA Joint Committee on Clinical Practice Guidelines; in collaboration with AATS, ASE, SCAI, SCA, STS
Type: Full revision clinical practice guideline (replacing 2014 guideline and 2017 focused update)
DOI: https://doi.org/10.1161/CIR.0000000000000923

Overview

This is the 2020 full revision of the ACC/AHA Valvular Heart Disease guideline, the definitive North American standard for VHD management. It introduces a unified A–D staging system across all valve lesions and provides evidence-based recommendations spanning diagnosis, medical management, and intervention for aortic, mitral, tricuspid, and pulmonic valve disease. Key advances include expanding TAVI indications with age-based SAVR vs TAVI selection criteria, formalising COAPT patient selection criteria for secondary MR TEER, and mandating multidisciplinary Heart Valve Team evaluation for all patients with severe VHD considered for intervention.

Keywords

Valvular heart disease, aortic stenosis, aortic regurgitation, bicuspid aortic valve, mitral stenosis, mitral regurgitation, transcatheter aortic valve replacement, mitral transcatheter edge-to-edge repair, tricuspid regurgitation, prosthetic valve, infective endocarditis, anticoagulation, guideline-directed management

Key Takeaways

Disease Staging System (Applies to All Valve Lesions)

Stage A (At Risk): Risk factors for VHD; normal valve anatomy and function
Stage B (Progressive): Progressive mild-moderate VHD; asymptomatic; normal or mildly abnormal haemodynamics
Stage C (Asymptomatic Severe):
- C1: Severe VHD; compensated LV/RV; normal LVEF
- C2: Severe VHD; LV/RV decompensation (LVEF <50% or LV/RV dilatation exceeding thresholds)
Stage D (Symptomatic Severe): Symptoms attributable to severe VHD
This staging framework guides both monitoring frequency and intervention thresholds for each valve lesion

General Diagnostic Principles

TTE is the standard first-line test for all patients with known or suspected VHD
Follow-up echo frequency is severity- and valve-specific (Stage B mild: 3–5 years; Stage B moderate: 1–2 years; Stage C1: 6–12 months)
Cardiac catheterisation reserved for discordant clinical/echo data
Exercise testing useful to unmask symptoms; contraindicated in symptomatic severe AS (Class III:Harm)
Biomarkers (BNP/NT-proBNP), GLS, and CT calcium scoring provide additive risk stratification

Multidisciplinary Heart Valve Team and Centres

Class I C-EO: All patients with severe VHD being considered for intervention must be evaluated by an MDT Heart Valve Team
Class IIa C-LD: Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable for: (1) asymptomatic patients with severe VHD; (2) potential repair candidates; (3) patients with multiple comorbidities
Primary vs Comprehensive Valve Centers differ in procedural scope (Comprehensive offers TEER, MV repair for anterior leaflet disease, multivalve surgery, reoperative surgery)

Aortic Stenosis — Grading and Staging

High-gradient (Stage D1): Vmax ≥4 m/s or mean PG ≥40 mmHg; AVA ≤1.0 cm² (AVAi ≤0.6 cm²/m²)
Very severe AS: Vmax ≥5 m/s or mean PG ≥60 mmHg
Stage D2 (low-flow, low-gradient, reduced LVEF): AVA ≤1.0 cm², Vmax <4 m/s, LVEF <50%; distinguish true severe from pseudo-severe with dobutamine stress echo (flow reserve = ≥20% SV increase)
Stage D3 (low-gradient, preserved LVEF): AVA ≤1.0 cm², SVi <35 mL/m², Vmax <4 m/s, LVEF ≥50% in normotensive state; CT calcium score helpful (>2000 AU men / >1300 AU women = severe)
Sex-specific CT calcium thresholds reflect greater contribution of leaflet fibrosis in women (lower threshold in women: 1300 AU vs 2000 AU in men)

Aortic Stenosis — Intervention

Class I A: Symptomatic severe high-gradient AS (Stage D1) → AVR
Class I B-NR: Asymptomatic severe AS with LVEF <50% (Stage C2) → AVR
Class I B-NR: Asymptomatic Stage C1 undergoing cardiac surgery for other reasons → AVR
Class I B-NR: Symptomatic low-flow, low-gradient severe AS with reduced LVEF (Stage D2) → AVR
Class I B-NR: Symptomatic Stage D3 (paradoxical low-flow) → AVR if AS most likely cause
Class IIa B-NR: Asymptomatic Stage C1 + low surgical risk + exercise-induced symptoms or ≥10 mmHg BP drop → AVR reasonable
Class IIa B-R: Asymptomatic Stage C1 + very severe AS (Vmax ≥5 m/s) + low risk → AVR reasonable
Class IIa B-NR: Asymptomatic Stage C1 + BNP >3× normal + low risk → AVR reasonable
Class IIa B-NR: Asymptomatic Stage C1 + Vmax progression ≥0.3 m/s/year + low risk → AVR reasonable
Class IIb B-NR: Asymptomatic Stage C1 + progressive LVEF decline to <60% on ≥3 serial studies → AVR may be considered
Annual event-free survival in severe AS (Vmax ≥4 m/s): only 30–50% at 2 years; sudden death risk <1%/year during prospective follow-up

TAVI vs SAVR Selection

Class I A: Age <65 years or life expectancy >20 years with indication for bioprosthetic AVR → SAVR recommended
Class I A: Age 65–80 years with no anatomic contraindication to transfemoral TAVI → either SAVR or TAVI after shared decision-making regarding longevity vs valve durability
Class I A: Age >80 years or life expectancy <10 years with no anatomic contraindication → transfemoral TAVI recommended in preference to SAVR
Class I A: Any age, high or prohibitive surgical risk, predicted post-TAVI survival >12 months with acceptable QoL → TAVI recommended
Class I A: Anatomy/vasculature not suitable for transfemoral TAVI → SAVR recommended
Evidence base: PARTNER 1 (high-risk), CoreValve High Risk, PARTNER 2 (intermediate), SURTAVI, PARTNER 3 (low-risk), Evolut Low Risk

Mechanical vs Bioprosthetic Valve Selection (AVR)

Class I C-EO: Choice based on shared decision-making; discuss anticoagulation risks and reintervention risks
Class I C-EO: Any contraindication to VKA → bioprosthetic valve
Class IIa B-R: Age <50 years without anticoagulation contraindication → mechanical prosthesis reasonable over bioprosthesis (15-year reoperation risk: 50% at age 20 y; 30% at age 40 y; 22% at age 50 y)
Class IIa B-NR: Age 50–65 years → individualise; debate unresolved; shared decision-making
Class IIa B-R: Age >65 years → bioprosthesis reasonable over mechanical (15-year SVD risk <10%; higher bleeding risk with VKA in elderly)
Class IIb B-NR: Age <50 years who prefer BHV + appropriate anatomy → Ross procedure may be considered at a Comprehensive Valve Center
For mitral valve: mechanical preferred if <65 years; bioprosthesis preferred if ≥65 years

Antithrombotic Therapy — Mechanical Valves

Class I A: All mechanical valve prostheses → VKA anticoagulation (lifelong)
Class I B-NR: Bileaflet or current-generation single-tilting disk aortic MHV + no risk factors → VKA targeting INR 2.5
Class I B-NR: Mechanical AVR + risk factors (AF, prior thromboembolism, LV dysfunction, hypercoagulable state, older-generation prosthesis) → VKA targeting INR 3.0
Class I B-NR: Mechanical mitral valve replacement → VKA targeting INR 3.0
Class IIb B-R: Mechanical AVR + VKA therapy + low bleeding risk → may add aspirin 75–100 mg
Class IIb B-R: On-X mechanical AVR (bileaflet) + no thromboembolic risk factors → lower INR target 1.5–2.0 starting ≥3 months post-surgery with aspirin 75–100 mg
Class III:Harm B-R: Dabigatran contraindicated in mechanical valves
Class III:Harm C-EO: Anti-Xa DOACs not recommended in mechanical valves

Antithrombotic Therapy — Bioprosthetic Valves

Class IIa B-R: After bioprosthetic TAVI, no other OAC indication → aspirin 75–100 mg daily reasonable
Class IIa B-NR: After bioprosthetic SAVR or MV replacement, no other OAC indication → aspirin 75–100 mg daily
Class IIa B-NR: After bioprosthetic SAVR/MV replacement + low bleeding risk → VKA (INR 2.5) for 3–6 months
Class IIb B-NR: After bioprosthetic TAVI, low bleeding risk → DAPT (ASA + clopidogrel 75 mg) for 3–6 months may be reasonable
Class III:Harm B-R: Low-dose rivaroxaban 10 mg + ASA after TAVI (without other OAC indication) is contraindicated (GALILEO-like harm)

Structural Valve Deterioration — Surveillance

~30% of surgical aortic BHV develop haemodynamic dysfunction (gradient increase ≥10 mmHg or worsening regurgitation) within 10 years after implantation
Risk factors for accelerated SVD (<5 years): age <60 years, smoking, diabetes, CKD, initial mean PG ≥15 mmHg
Class IIa C-LD: Surgical BHV → TTE at 5 and 10 years then annually after implantation even without symptoms
Class IIa C-LD: Bioprosthetic TAVI → annual TTE is reasonable
Mechanical valves with normal baseline study: routine annual TTE not needed unless clinical change
Patients typically remain asymptomatic until dysfunction is severe; early detection is the purpose of surveillance

AF and Anticoagulation in VHD

For most VHD with AF (except rheumatic mitral stenosis or mechanical prosthesis): anticoagulation decision based on CHA2DS2-VASc score; either VKA or NOAC acceptable
Rheumatic mitral stenosis + AF: VKA required (not NOACs)
Mechanical prosthesis + AF: VKA required (not NOACs)
Note: ACC/AHA 2020 uses CHA2DS2-VASc (includes sex); contrast with 2024 ESC which uses CHA2DS2-VA (sex removed)

Aortic Regurgitation

Asymptomatic Stage C1 (severe AR, LVEF ≥50%, LVESD <50 mm) → periodic surveillance; AVR at symptom onset
Class I B-NR: AR with LVEF <50% → AVR
Class I B-NR: Severe AR; AVR indicated; undergoing other cardiac surgery → concomitant AVR
Class IIa B-NR: Asymptomatic severe AR with progressive LV dilation (LVESD ≥50 mm or LVEDD ≥65 mm) → AVR reasonable
TAVI for isolated AR: rarely feasible; only in prohibitive surgical risk patients with appropriate anatomy; risk of valve migration and significant PVL
BAV-associated aortopathy: aortic replacement recommended if sinuses or ascending aorta >5.5 cm; reasonable at 5.0–5.5 cm if additional risk factors (family history, growth rate >0.5 cm/year, coarctation) at Comprehensive Valve Center

Primary Mitral Regurgitation — Intervention

Class I B-NR: Symptomatic severe PMR (Stage D) → MV intervention regardless of LVEF
Class I B-NR: Asymptomatic severe PMR with LVEF ≤60% or LVESD ≥40 mm (Stage C2) → MV surgery
Class I B-NR: Severe PMR with surgical indication → MV repair recommended over replacement when anatomically feasible in degenerative disease
Class IIa B-NR: Asymptomatic Stage C1 severe PMR (LVEF ≥60%, LVESD ≤40 mm) → MV repair reasonable when likelihood of successful durable repair >95% and expected mortality <1% at a Primary or Comprehensive Valve Center
Class IIa B-NR: Severely symptomatic (NYHA III/IV) severe primary MR + high/prohibitive surgical risk → TEER reasonable if anatomy favourable and life expectancy ≥1 year
Repair vs replacement: Hospital mortality 50% lower in highest-volume hospitals (≥50 repairs/year); freedom from moderate/severe MR 60% at 15–20 years for complex repairs
Vasodilator therapy: NOT indicated in asymptomatic PMR with normal LVEF and normotension (Class III:No Benefit)

Secondary Mitral Regurgitation

Class IIa B-NR: Severely symptomatic secondary MR (NYHA III/IV) despite GDMT → TEER reasonable if COAPT criteria met
COAPT selection criteria: LVEF 20–50%; LVESD ≤70 mm; PASP ≤70 mmHg; persistent NYHA II–IV on optimal GDMT; no CAD requiring revascularisation
MITRA-FR vs COAPT divergence: MITRA-FR enrolled larger LV (LVESD up to 70 mm), lower mean EROA (0.31 vs 0.41 cm²), less rigid GDMT — resulted in no benefit; COAPT criteria now define the standard selection
Class I B-NR: Severe secondary MR + CAD → MV surgery at time of CABG
Note: At time of 2020 guideline, TEER for secondary MR was Class IIa; subsequently upgraded to Class I A by ESC 2025 based on RESHAPE-HF2

Tricuspid Regurgitation — Intervention

Class I B-NR: Severe TR (Stages C and D) undergoing left-sided valve surgery → concomitant TV surgery
Class IIa B-NR: Progressive TR (Stage B) undergoing left-sided surgery + annular dilation (>4.0 cm) or prior right-HF signs → TV surgery beneficial
Class IIa B-NR: Symptomatic severe primary TR (Stage D) → isolated TV surgery can reduce symptoms and hospitalisations
Class IIa B-NR: Symptomatic Stage D isolated secondary TR from annular dilation (no PH or LV systolic dysfunction) poorly responsive to medical therapy → isolated TV surgery beneficial
Operative mortality for isolated TR surgery historically 8–20% when performed after end-organ damage; better outcomes with earlier intervention before RV dysfunction

Infective Endocarditis Prophylaxis

Class IIa C-LD: Antibiotic prophylaxis before dental procedures (gingival manipulation, periapical region, oral mucosa perforation) is reasonable in patients with: prosthetic valves (including TAVI), prior IE, prosthetic material for repair, unrepaired cyanotic CHD, cardiac transplant with regurgitation from structurally abnormal valve
Class III:No Benefit B-NR: IE prophylaxis NOT recommended for non-dental procedures (TEE, EGD, colonoscopy, cystoscopy) in absence of active infection
IE after TAVI: rate equals or exceeds SAVR-associated IE; 1-year mortality 75% — underscores importance of prophylaxis

Rheumatic Fever Secondary Prophylaxis

Duration ≥10 years or until age 40 (whichever longer) for rheumatic heart disease with persistent VHD
Lifelong prophylaxis if high-risk of group A streptococcus exposure
Required even after valve replacement

VHD in Pregnancy

Mechanical prosthetic valves: VKA preferred throughout pregnancy for lowest thromboembolic risk; UFH acceptable if patient refuses warfarin (first trimester); LMWH acceptable alternative with anti-Xa monitoring
NOACs: contraindicated throughout pregnancy in mechanical valve patients
Native VHD: most women with repaired or mildly symptomatic VHD tolerate pregnancy well; severe AS and severe MS carry highest pregnancy risk (class III maternal risk); aortic valve intervention before pregnancy if severe AS

Limitations of the Document

Evidence base predominantly from observational studies and registries; relatively few RCTs specific to VHD
TAVI durability data extend to only ~5 years at time of publication — critical gap for younger patients
Secondary MR recommendations heavily influenced by single RCT (COAPT); MITRA-FR divergence not fully reconciled
VHD in younger patients (pregnancy, Ross procedure, valve-in-valve planning) has limited prospective RCT data
BAV patients largely excluded from major TAVI RCTs
Sex-specific differences in VHD outcomes underrepresented in trial populations
Literature search cut-off March 1, 2020; rapid evolution of TAVI evidence and TEER evidence has already partially superseded some recommendations

Key Concepts Mentioned

concepts/Valvular-Heart-Disease — comprehensive guidelines basis
concepts/Aortic-Stenosis — A–D staging, TAVI vs SAVR age-based selection
concepts/TAVI — evidence base, PARTNER/Evolut trial series
concepts/Aortic-Regurgitation — intervention thresholds, BAV management
concepts/Primary-Mitral-Regurgitation — repair vs replacement, TEER indications
concepts/Secondary-Mitral-Regurgitation — COAPT criteria, MITRA-FR divergence
concepts/Tricuspid-Regurgitation — concomitant and isolated surgery indications
concepts/Mitral-Stenosis — rheumatic and calcific MS; PMBC criteria
concepts/Structural-Valve-Deterioration — TTE surveillance schedule; SVD risk factors
concepts/Heart-Valve-Centre — Primary vs Comprehensive Valve Center structure

Key Entities Mentioned

entities/Atrial-Fibrillation — anticoagulation strategy with VHD (CHA2DS2-VASc)
entities/Heart-Failure — GDMT in secondary MR; heart failure management in VHD

Wiki Pages Updated

wiki/sources/VHD-AHA-2020.md — created
wiki/concepts/Valvular-Heart-Disease.md — updated
wiki/concepts/Aortic-Stenosis.md — updated
wiki/concepts/TAVI.md — updated
wiki/concepts/Primary-Mitral-Regurgitation.md — updated
wiki/concepts/Secondary-Mitral-Regurgitation.md — updated
wiki/concepts/Structural-Valve-Deterioration.md — updated
wiki/concepts/Tricuspid-Regurgitation.md — updated
wiki/sourceindex.md — updated
wiki/wikiindex.md — updated