Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811

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Journal of Cardiothoracic and Vascular Anesthesia

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Expert Review

Analysis of the 2021 European Society of Cardiology/

European Association for Cardio-Thoracic Surgery
Guidelines for the Management of Valvular
Heart Disease
Carson C. Welker, MD*, Jeffrey Huang, MD, MSy,
Maryna Khromava, MDz, Michael R. Boswell, MDz,
u~
Iv
an J. N
nez Gil, MD, PhD, FESC{,**, 1
Harish Ramakrishna, MD, FACC, FESCx,||,
*
Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
y
Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
z
Department of Anesthesiology, Mayo Clinic, Rochester, MN
x
Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Rochester, MN
||
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
{
Interventional Cardiology, Cardiovascular Institute, Hospital Cl
ınico San Carlos, Madrid, Spain
**
Biomedical Science Faculty, Universidad Europea de Madrid, Madrid, Spain

Aortic Stenosis symptoms are detected as early as possible.4 Moderate AS

In North America and Europe, aortic stenosis (AS) is caused
commonly by degenerative calcific valvular disease among
patients aged 75, with a 12.4% prevalence (including a 3.4%
prevalence of severe disease).1 Among younger patients, a
bicuspid aortic valve is the predominant etiology.2 Worldwide,
infectious etiologies remain the most common cause of AS,
with rheumatic fever (primarily) and infective endocarditis as
leading mechanisms.2
Symptomatic AS is a key prognostic factor, with classic
symptoms being heart failure, angina, and syncope. In the
absence of intervention, the average survival rate is 2-to-
3 years after symptom onset.3 By comparison, patients with
asymptomatic AS have an approximately 1% annual risk of
sudden death.3 Because of the wide variability in the rate of
AS progression and significance of symptom onset, the expert
consensus emphasizes regular follow-up for patients with
asymptomatic severe AS at least every 6 months so that
1
Address correspondence to Harish Ramakrishna, MD, Division of Cardio-
vascular and Thoracic Anesthesiology, Department of Anesthesiology and
Perioperative Medicine, Mayo Clinic, 200 First St. SW, Mayo Clinic, Roches-
ter, MN 55905
E-mail address: ramakrishna.harish@mayo.edu (H. Ramakrishna).
should be followed at least annually, and mild AS may be reas-
sessed every 2-to-3 years.4
Evaluation
Because of the poor natural prognosis of symptomatic
severe high-gradient AS, the expert consensus strongly recom-
mends early intervention in these patients. The expert consen-
sus now includes aortic valve area of 1.0 cm2 or 0.6 cm2/
m2 as a criterion for intervention. Mean gradient and peak
velocity also have been added as criteria for intervention to
help capture patients with low-flow severe AS.4,5 For asymp-
tomatic patients, another change in the 2021 guidelines is to
consider intervention in the cases of asymptomatic severe AS
with systolic left ventricular (LV) dysfunction (with an ejec-
tion fraction <55%) without another cause. This is in addition
to the existing recommendation to intervene when LV ejection
fraction (LVEF) is <50%. By contrast, the 2020 American
College of Cardiology/American Heart Association continues
to use a cutoff of LVEF <50% as the threshold for intervention
in this population.6 Observational data show that, among
patients with asymptomatic AS, an LVEF <60% is the

https://doi.org/10.1053/j.jvca.2023.01.008
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804 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811
variable most strongly predictive of increased all-cause mor-
tality (hazard ratio 5.01, 95% CI 2.93-8.57, p < 0.001).7
Interventions
Options for intervention include surgical aortic valve
replacement (SAVR) and transcatheter aortic valve implanta-
tion (TAVI). Transcatheter aortic valve implantation is associ-
ated with higher rates of vascular complications, the need
for pacemaker implantation, and paravalvular regurgitation,
whereas SAVR is associated with higher rates of severe bleed-
ing, acute kidney injury, and new-onset atrial fibrillation.4 In
intermediate-risk AS patients, advantages of TAVI compared
with SAVR include shorter intensive care and hospital lengths
of stay, greater quality-adjusted life expectancy, and lower
long-term costs.8 Balloon aortic valvotomy may be used as a
bridge to SAVR or TAVI for hemodynamically unstable
patients or for patients with severe AS who require urgent
high-risk noncardiac surgery.
Indications for SAVR in asymptomatic patients with LVEF
>55% remain mostly unchanged: low procedural risk and
presence of either very severe aortic stenosis, severe valve cal-
cification with rapid progression of peak velocity, or markedly
elevated brain natriuretic peptide levels without alternative
explanation.4 The expert consensus has broadened the defini-
tion of very severe AS from Vmax >5.5 m/s to either Vmax
>5.0 m/s or mean gradient 60 mmHg. The expert consensus
also eliminated the indication of severe pulmonary hyperten-
sion for intervention in these patients. Surgical aortic valve
replacement remains recommended in patients with severe AS
who are undergoing coronary artery bypass grafting (CABG)
or surgery on another valve or the ascending aorta.
Among patients who are at low risk for surgery, the expert
consensus now explicitly includes an age threshold of 75 years
in the decision to recommend SAVR versus TAVI. The expert
consensus also added a recommendation to consider nontrans-
femoral TAVI in patients who are not candidates for either
SAVR or transfemoral TAVI.4 The criteria for severe AS and
interventions are included in Table 1.4
Aortic Regurgitation
In high-income countries, aortic regurgitation (AR) or aortic
insufficiency is most commonly caused by degenerative
disease of the aortic valve cusps.9 Other etiologies include
infective endocarditis, rheumatic endocarditis, and aortic dis-
section. Patients with severe AR and New York Heart Associa-
tion (NYHA) class II symptoms have an annual mortality rate
of 6%; this drastically increases to 25% per year with New
York Heart Association class III or class IV symptoms.10
Evaluation
Aortic regurgitation should be evaluated with echocardiog-
raphy. The criteria are listed in Table 24,11 and include a com-
bination of qualitative, semiquantitative, and quantitative
measurements and observations. Computed tomography or
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Table 1
Criteria for Severe AS and Indications for Intervention4
High-gradient severe AS criteria:
ΔPm 40 mmHg; Vmax 4.0 m/s; AVA 1 cm2 or 0.6 cm2/m2
Low-gradient, low-flow severe AS criteria:
ΔPm <40 mmHg; Vmax <4 m/s; AVA 1 cm2; SVi 35 mL/m2; LVEF
<50% (or preserved LVEF if all other explanations for low gradient have
been excluded)
Symptomatic severe AS (dyspnea or heart failure symptoms, angina,
presyncope, or syncope)
Asymptomatic severe AS and LVEF <55% without alternative explanation
Asymptomatic severe AS and symptoms on exercise testing
Asymptomatic severe AS and sustained BP drop >20 mmHg during exercise
testing
Asymptomatic severe AS and LVEF >55% with normal exercise test, low
procedural risk, and one of the following:
Very severe AS (ΔPm 60 mmHg or Vmax 5 m/s)
Severe valve calcification and Vmax progression 0.3 m/s/y
Markedly elevated BNP levels >3x age-/sex-corrected normal range without
alternative explanation
Severe AS and undergoing CABG or surgery of the ascending aorta or another
valve
Abbreviations: AS, aortic stenosis; AVA, aortic valve area; BNP, B-type
natriuretic peptide; CABG, coronary artery bypass grafting; LVEF, left
ventricular ejection fraction; ΔPm, mean pressure gradient; SVi, stroke volume
index; Vmax, peak transvalvular velocity.
cardiac magnetic resonance (CMR) imaging may be useful
adjuncts when echocardiographic findings do not cleanly fit
these criteria.
Table 2
Criteria for Severe AR and Indications for Surgery in Patients With Severe
AR4,11
Qualitative criteria for severe AR
Abnormal/flail valve morphology or large coaptation defect
Large central regurgitant jet (65% of left ventricular outflow tract)
Dense continuous wave signal of regurgitant jet
Holodiastolic flow reversal in descending aorta (end-diastolic velocity
>20 cm/s)
Semiquantitative criteria for severe AR
Vena contracta width >6 mm
Pressure half-time <200 ms
Quantitative criteria for severe AR
EROA 30 mm2
Regurgitant volume 60 mL/beat
LV dilatation
Symptomatic severe AR
Asymptomatic severe AR with LVEF 50% or LVESD >50 mm or LVESD
>25 mm/m2
Asymptomatic severe AR with LVEF 55% or LVESD >20 mm/m2 BSA if
low surgical risk
Severe AR if undergoing CABG or surgery of the ascending aorta or another
valve
Abbreviations: AR, aortic regurgitation; BSA, body surface area; CABG,
coronary artery bypass grafting; EROA, effective regurgitant orifice area; LV,
left ventricle; LVEF, left ventricular ejection fraction; LVESD, left ventricular
end-systolic diameter.
 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811
Medical Management
Afterload reduction with angiotensin-converting enzyme
inhibitors or dihydropyridine, calcium channel blockers, may
help improve symptoms in patients who are not surgical candi-
dates. However, there is no evidence to support using these
medications as a method of delaying surgery. Patients with
Marfan syndrome should be placed on beta-blockers to reduce
shear stress.
Patients with newly diagnosed AR or whose LV diameter or
EF is changing rapidly and/or nearing thresholds for surgery
should be followed-up every 3-to-6 months. Patients who have
asymptomatic severe AR and normal LV function should be
followed-up at least once a year. Patients with a dilated
ascending aorta (>40 mm) on echocardiography should be
assessed with cardiac computed tomography or CMR imaging.
Interventions
Urgent surgery for acute aortic regurgitation may be indi-
cated in the setting of infective endocarditis, aortic dissection,
chest trauma, or iatrogenic complications from catheter-based
interventions.12 Surgery is recommended for symptomatic
patients regardless of LVEF as long as surgical risk is appro-
priate. Surgery also is indicated regardless of symptoms in
patients who are undergoing CABG or surgery of the ascend-
ing aorta or another valve. Surgery is indicated for asymptom-
atic patients who develop impairment of the left ventricle
(LVEF 50% or LV end-systolic diameter [LVESD]
>50 mm) due to the association with worse outcomes in these
patients in the absence of intervention. Surgery may be reason-
able in patients with LVEF between 50% and 55% and
(LVESD) >20 mm/m2 with low surgical risk. Significant LV
end-diastolic diameter (>65 mm) also may suggest a need for
surgery. Note that the LV end-diastolic diameter cutoff was
previously 70 mm in the 2017 guidelines but is now 65 mm, in
line with the current expert consensus.5,6
Surgical aortic valve replacement remains the standard for
most patients with AR. Valve-sparing root replacement, valve
repair, and the Ross procedure may be reasonable alternatives
in certain circumstances when performed by experienced sur-
geons/proceduralists. The expert consensus clarified this rec-
ommendation to include young patients with aortic root
Table 3
Qualitative and Quantitative Qualities That Define Primary and Secondary Mitral Regurgitation
Primary mitral regurgitation
Etiology Papillary rupture, endocarditis, calcification, inflammatory disease,
rheumatism
Valve morphology Papillary rupture, flail leaflet
EROA 40 mm2
Regurgitant volume 60 mL
Regurgitant fraction 50%
Pulmonary vein flow Systolic flow reversal
Abbreviation: EROA, effective regurgitant orifice area.
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805
dilation when performed in an experienced center, and durable
results are expected.4
Patients with connective tissue diseases such as Marfan syn-
drome require regular follow-up with specialists due to the
risk of aortic dissection. Specifically, the size and rate of
growth of the proximal aorta should be monitored routinely,
typically via echocardiography.13 First-degree relatives should
be referred for genetic testing and screening imaging studies.
Mitral Regurgitation
Mitral regurgitation (MR) is the second most common val-
vular disease in Western countries, occurring in almost 9% of
the US population older than 75.14 Mitral regurgitation occurs
either because of primary degeneration of the mitral valve,
referred to as "primary MR" (PMR), or as a consequence of
geometric derangements of the left ventricle or left atria,
referred to as "secondary MR" (SMR). The causes of PMR
include calcification, endocarditis, inflammatory disease,
rheumatism, as well as idiopathic changes. Secondary MR
can result from ischemic or nonischemic LV remodeling as
well as atrial distention with annular dilation and poor valve
coaptation.15
Evaluation
Evaluation with echocardiography aims to characterize
the grade of regurgitation with both qualitative and quanti-
tative measures to determine the need for medical manage-
ment, surgical care, or transcatheter repair. The effective
regurgitant orifice area is measured routinely, as it has a
strong association with mortality, especially with values
30 mm2.16 The expert consensus advocates for CMR
imaging when there is echocardiographic inconsistency or
inadequacy to better characterize regurgitant and chamber
volumes. Numerous prospective studies confirm the recom-
mendation for CMR, demonstrating high accuracy mortality
prognostication based on measured regurgitant volume.14
The Mitral Regurgitation International Database Mortality
Risk Score has been used to estimate risk of all-cause mor-
tality in severe PMR. The Mitral Regurgitation Interna-
tional Database score has been externally validated to
differentiate mortality after medical or surgical manage-
ment, and appears to be a useful tool to guide
Secondary mitral regurgitation
Geometric annular change, cardiac remodeling, chronic dilation
Poor leaflet coaptation
40 mm2
60 mL
50%
Systolic flow reversal
806 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811

management.17 Other quantitative and qualitative criteria to randomized controlled trials have shown that TEER also is
diagnose severe MR can be found in Table 3. safe and may reduce regurgitation for up to 3 years,
The expert consensus recommends that asymptomatic although the criteria for TEER remain controversial.9,26,27
patients with severe MR and LVEF >60% be followed up The expert consensus recommends using the COAPT (Car-
every 6 months with serial echocardiography, based on a long- diovascular Outcomes Assessment of the MitraClip Percu-
term outcome study that demonstrated excellent survivability taneous Therapy) inclusion criteria, which are tiered based
over an almost 20-year period.18 When LVESD approaches on the degree of effective regurgitant orifice area, along
40 mm with decreasing LVEF, surgical options should be with other echocardiographic signs of regurgitant volume
considered. and velocities.28
PMR Management
Urgent surgical intervention is required with acute and
Mitral Stenosis
severe PMR, especially in the case of papillary rupture.
When MR is chronic and severe, surgical intervention is
Mitral stenosis is estimated to comprise 12% of all single-
dictated by symptomatology, LV function, atrial pathology,
valve pathologies in population-based studies, with the great
and risk stratification. The expert consensus recommends
majority (>99%) due to rheumatic heart disease, which is
surgical intervention in the presence of LVEF 60%,
characterized by commissural adhesions and leaflet fibrosis.29
LVESD 40 mm, left atrial volume 60 mL/m2 (or diame-
The incidence of rheumatic-associated mitral stenosis is esti-
ter >55 mm), systolic pulmonary arterial pressure 50
mated at <2 cases per 100,000 in the United States, and 150
mmHg, and atrial fibrillation, as these conditions are all
per 100,000 worldwide, with certain patient demographics at
associated with worse outcomes with MR.19
particular risk (ie, female sex, age 30-60 years old, lower edu-
The expert consensus class 1B recommendation of mitral
cation level, and poverty).30-32 Less-common causes of mitral
valve repair over replacement is substantiated by a fairly
stenosis include mitral annular calcification (age-related cal-
robust analysis showing all-cause early mortality reduction,
cific degeneration of the mitral annulus extending into the leaf-
with a hazard ratio of 1.47 compared with 4.51, as well as 20-
let bases), chest radiation, obstructing intracardiac masses, and
year survivability of 46% versus 23%, respectively.20,21 In
inherited metabolic diseases.33
cases of severe MR in patients undergoing CABG, a valve
repair or replacement also is generally recommended.22
Evaluation
Degenerative valve changes may be severe enough to render
repair unfeasible, requiring surgical replacement. Some studies
Although several different diagnostic tests are used in the
suggest equal outcomes with repair over replacement; how-
evaluation of mitral stenosis (eg, angiography, fluoroscopy,
ever, lower-risk patients may have a survival benefit when
stress testing, etc), the expert consensus recommends echocar-
undergoing a repair.23 Transcatheter Edge-to-Edge Repair
diography and clinical history as the primary methods of eval-
(TEER) is a safe alternative for patients who have contraindi-
uation. Echocardiographic indices of severity include mitral
cations for high-risk surgery. At 1 year, residual moderate-to-
valve area, the mean pressure gradient across the mitral valve,
severe MR after TEER can occur in 20%-to-30% of patients.
pressure half-time, valve anatomy, pulmonary artery pressure,
A follow-up of a randomized population who had surgical
and associated lesions.34 The expert consensus defines clini-
repair versus TEER showed a 5-year equal durability of MR
cally significant mitral stenosis as having a surface area of
recurrence.24
1.5 cm2. Furthermore, the European Association of Echocar-
SMR Management
diography and the American Society of Echocardiography
Secondary mitral regurgitation management is far more
have published echocardiographic values, which delineate the
complex than PMR management. Identical quantitative
severity of mitral stenosis using valve area, mean gradient, and
echocardiographic measurements between PMR and SMR
pulmonary artery pressure, demonstrated in Table 4.34
should not be treated the same. A lower threshold for treat-
Untreated severe rheumatic mitral stenosis remains one of
ment should be applied in SMR because LV stroke volume
the most fatal cardiac valvular pathologies. In the presence of
may be lower, which can lead to underestimation of regur-
symptoms, 5-year mortality rates are as high as 56%, with
gitant volume. The expert consensus offers caution when
right-heart failure being the most common cause of death
diagnosing SMR based solely on echocardiographic find-
ings, as the underlying disease process may be more
advanced when compared with PMR. A patient with a life Table 4
expectancy of more than 1 year and persistent symptoms Mitral Stenosis Severity
while on maximized medical therapy for heart failure
Finding Mild Moderate Severe
should be considered for surgical intervention. As with
PMR, valve repair or replacement should be done when Valve area (cm2)* >1.5 1.0-1.5 <1.0
undergoing CABG, as a class 1B recommendation.25 Mean gradient (mmHg)y <5 5-10 >10
Because valve replacement has not been shown to translate Pulmonary artery pressure (mmHg)y <30 30-50 >50
into LV reverse remodeling or survival, valve repair is * Specific findings.
often the preferred surgical management.25 Recent y Supportive findings.

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 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811
(27.7% of patients).35 Morbidity of untreated mitral stenosis
can be predicted based on left atrial size, severity of stenosis,
and presence/absence of normal sinus rhythm. In the case of a
dilated left atrium (47 mm), the risk of atrial fibrillation
development has been measured at 6% per year.36
Medical Management
The role of medical management in mitral stenosis is lim-
ited, and no universal guidelines exist to date. Categories of
pharmaceutical treatment include anticoagulation (if atrial
arrhythmia is present), treatment of heart failure symptoms,
heart rate versus heart rhythm control, and secondary preven-
tion of rheumatic fever (eg, antibiotics and ready access to
healthcare).33
At the time of this analysis, the expert consensus recom-
mends warfarin as the anticoagulant of choice in patients with
atrial fibrillation and mitral stenosis. The use of direct oral
anticoagulants for anticoagulation in valvular atrial fibrillation
shows promise in retrospective studies, and is the current topic
of a randomized controlled trial.37,38 Class 1 recommendations
for anticoagulation include the presence of atrial fibrillation,
prior thrombotic events, and left atrial thrombus.33 Although
no international ratio goal is universally established, an inter-
national ratio of 2-to-3 is cited in the literature for this clinical
context.37
Heart failure symptoms are palliated by diuretics and salt
restriction.39 Digoxin is not usually the first-line treatment, as
patients with mitral stenosis tend to have preserved ventricular
function, with heart rate control being achievable by alterna-
tive methods. Rate control (heart rate 60-to-80 beats/min in
most adults), or rhythm control (preservation of sinus rhythm)
are targeted in these patients to enhance atrial kick and dia-
stolic transmitral blood flow.40
Interventions
The expert consensus recommends that patients with asymp-
tomatic mitral stenosis receive repeat echocardiography every
year (for severe stenosis), or every 2-to-3 years (for moderate
stenosis). Intervention consists of percutaneous mitral com-
missurotomy (PMC) or mitral valve replacement surgery. The
expert consensus has provided recommendations for the type
and timing of intervention based on symptoms, risk of embo-
lism, hemodynamic stability, valve anatomy, surgical risk, and
specific valve characteristics, shown in Tables 5 and 6. Indica-
tions for PMC and surgery have not changed since 2017.
Contraindications to PMC include mitral valve area >1.5
cm2, left atrial thrombus, mitral regurgitation more than mild in
severity, severe bicommissural calcification, absence of com-
missural fusion, certain concomitant valvular pathologies (aor-
tic valve disease or severe combined tricuspid stenosis/
regurgitation) requiring surgery, and concomitant coronary
artery disease requiring bypass surgery. Anatomic characteris-
tics that deem PMC favorable are based on the validated fluoro-
scopic and echocardiographic assessments of the Cormier
Score (grades the degree of mitral valve calcification) and the
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807
Table 5
Indications for Intervention in Asymptomatic Patients With Severe Mitral Ste-
nosis (MVA 1.5 cm2)
High Risk of Embolism or HD Decompensation is Present
PMC
Surgical mitral valve replacement (if contraindications to PMC*/unfavorable
characteristicsy are present)
High Risk of Embolism or HD Decompensation is NOT Present
Surgical mitral valve replacement (if symptoms are reproducible with exercise
testing and contraindications to PMC*/unfavorable characteristicsy are
present)
PMC (if symptoms are reproducible with exercise testing and NO
contraindications to PMC*/unfavorable characteristicsy are present)
Observation (if symptoms are NOT able to be reproduced by exercise testing)
Abbreviations: AF, atrial fibrillation; CAD, coronary artery disease; HD,
hemodynamic; LA, left atrium; MVA, mitral valve area; PMC, percutaneous
mitral commissurotomy.
* MVA >1.5 cm2, LA thrombus, more than moderate mitral regurgitation,
severe or bicommissural calcification, absence of commisural fusion,
severe concomitant aortic valve disease, severe combined tricuspid steno-
sis and regurgitation requiring surgery, and concomitant CAD requiring
surgery.
y Old age, history of commissurotomy, New York Heart Association class
IV, permanent AF, severe pulmonary hypertension, echocardiographic
score >8, Cormier score 3 (calcification of mitral valve of any extent as
assessed by fluoroscopy), very small MVA, and severe tricuspid
regurgitation.
Echocardiographic Score (accounts for anatomic measurements
of the mitral valve apparatus), respectively.41,42 All mitral
lesions characterized as Cormier group 3 (mitral valve calcifica-
tion of any extent) or associated with an Echocardiographic
Score >8 (demonstrating a combination of small mitral valve
area, decreased leaflet displacement, large commissural
area ratio, or subvalvular involvement) are described as
“unfavorable characteristics” for PMC. Because of a decreasing
frequency in rheumatic heart disease, the incidence of PMC
also has been decreasing over the past 20 years, and lack of
familiarity with this procedure influences procedure selection.43
Table 6
Indications for Intervention in Symptomatic Patients With Severe Mitral Ste-
nosis (MVA 1.5 cm2)
Contraindications to PMC* are Present
Surgical mitral valve replacement
Contraindications to PMC* NOT Present
PMC (if no contraindications or high risk features for surgery are present)
Surgical mitral valve replacement (if nonfavorable characteristicsy are present)
Abbreviations: AF, atrial fibrillation; CAD, coronary artery disease; LA, left
atrium; MVA, mitral valve area; PMC, percutaneous mitral commissurotomy.
* MVA >1.5 cm2, LA thrombus, more than moderate mitral regurgitation,
severe or bicommissural calcification, absence of commisural fusion,
severe concomitant aortic valve disease, severe combined tricuspid steno-
sis and regurgitation requiring surgery, and concomitant CAD requiring
surgery.
y Old age, history of commissurotomy, New York Heart Association class
IV, permanent AF, severe pulmonary hypertension, echocardiographic
score >8, Cormier score 3 (calcification of mitral valve of any extent as
assessed by fluoroscopy), very small MVA, and severe tricuspid
regurgitation.
808 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811

The incidence of mitral stenosis due to mitral annular calci-
fication is difficult to estimate. Mitral stenosis may occur in up
to 2.2% of the time when mitral annular calcification is pres-
ent, with a higher incidence in the older population.44 Disease
prognosis is challenging to measure because this process usu-
ally presents with concomitant valvular pathologies. In gen-
eral, the procedural risk with percutaneous interventions is
high in this condition, with intraprocedural LV outflow tract
obstruction a particular cause for concern.45 Surgical mortality
remains high due to several indices of comorbidity in this
patient population.46
Tricuspid Regurgitation
Tricuspid regurgitation (TR) is a common finding in up to
90% of the general population.47 Older patients almost univer-
sally present with trivial or mild TR on routine echocardiogra-
phy. The presence of moderate or severe TR is significantly
lower. Moderate or severe TR is observed in <1 % of the gen-
eral population, and its prevalence also increases with age.48
The most common etiology of TR is secondary, associated
with pressure and/or volume overload in the setting of left-
sided valvular or ventricular dysfunction, or isolated right ven-
tricular (RV) dysfunction.48 Causes of primary TR include
either congenital valve dysplasia (ie, in the setting of Ebstein
anomaly) or organic, such as from infectious endocarditis,
autoimmune disease, carcinoid syndrome, trauma, or iatro-
genic injury.48 The 2021 expert consensus mentions for the
first time atrial fibrillation as one of the independent causes of
tricuspid annular remodeling. The consensus also highlights
the high risk of developing TR after cardiac implantable elec-
tronic device-lead implantation.49-51
Evaluation
Echocardiography remains the ideal technique for evalua-
tion of primary and secondary tricuspid regurgitation. The
expert consensus acknowledges the limitations of the existing
RV function indices. Along with RV dimensions and function,
the expert consensus considers RV strain and 3-dimensional
echocardiography measurements of RV volumes as beneficial
when performed in experienced laboratories.52 Unchanged
from the prior guidelines, CMR imaging remains the gold stan-
dard for assessing RV volumes and function. Cardiac magnetic
resonance also allows for the calculation of the tricuspid regur-
gitant volume by RV volumetry.52 Three-dimensional vena
contracta measurement results in a better estimation of tricus-
pid regurgitation severity by the proximal isovelocity surface
area method due to the nonplanar shape of the tricuspid valve
orifice, and should be considered in addition to the conven-
tional 2-dimensional measurement.53 Expert consensus also
comments on the new grading scheme of the tricuspid valve
severity (including mild, moderate, severe, massive, and tor-
rential grades) and its prognostic value in terms of patient mor-
tality and morbidity.54-56 Cardiac catheterization again is not
recommended, except in cases of pulmonary hypertension, to
evaluate pulmonary vascular resistances.57 The criteria defin-
ing tricuspid regurgitation can be found in Table 7.
Medical Management
Medical management is recommended in severe primary
asymptomatic TR without RV involvement. Patients with
severe secondary TR who are not candidates for intervention
due to severe pulmonary hypertension or RV and/or LV dys-
function also may be managed medically. In patients with
right-heart failure, diuretics are recommended, and aldosterone
antagonists may be considered.58 Atrial fibrillation and pulmo-
nary hypertension treatment also may help with the progres-
sion of TR.59 Most importantly, the expert consensus asserts
that medical management should concur with an early referral
for surgery or transcatheter therapy.
The expert consensus does not comment on the frequency of
surveillance cardiac examinations in patients with known TR,
although the consensus recommends treating TR before irre-
versible RV damage occurs. Surgery is still recommended
over nonsurgical intervention options. Tricuspid annuloplasty
with prosthetic rings also is still recommended over valve
replacement.60
Interventions
Transcatheter tricuspid valve technologies are mentioned
for the first time in the current expert consensus.61,62

Table 7
Qualitative and Quantitative Qualities That Define Primary and Secondary Tricuspid Regurgitation

Primary Tricuspid Regurgitation Secondary Tricuspid Regurgitation

Etiology Congenital, infectious endocarditis, autoimmune disease, Pressure/volume overload, cardiac remodeling, annular
carcinoid syndrome, trauma, iatrogenic injury dilatation
Valve morphology Structural abnormality, flail leaflet Poor leaflet coaptation
EROA (mm2) 40 mm2 40 mm2
Regurgitant volume (mL/beat) 60 mL 60 mL
Vena contracta width (mm) >7 >7
PISA radius (mm) >9 >9
Hepatic vein flow Systolic flow reversal Systolic flow reversal

Abbreviations: EROA, effective regurgitant orifice area; PISA, proximal isovelocity surface area.

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Table 8
Indications for Surgery in Patients With Primary and Secondary Tricuspid
Regurgitation
Primary tricuspid regurgitation
Severe primary tricuspid regurgitation if undergoing left-sided valve surgery
Moderate primary tricuspid regurgitation if undergoing left-sided valve
surgery
Isolated severe primary tricuspid regurgitation if symptomatic without
severe RV dysfunction
Isolated severe primary tricuspid regurgitation if asymptomatic with RV
dilatation
Secondary tricuspid regurgitation
Severe secondary tricuspid regurgitation if undergoing left-sided valve surgery
Mild or moderate secondary tricuspid regurgitation with tricuspid annulus
40 mm2 if undergoing left-sided valve surgery
Severe secondary tricuspid regurgitation if symptomatic or have RV
dilatation without severe RV or LV dysfunction and pulmonary vascular
disease
Severe secondary tricuspid regurgitation if symptomatic and inoperable can
be considered for transcatheter treatment
Abbreviations: LV, left ventricle; RV, right ventricle.
Transcatheter treatment of symptomatic secondary severe
TR may be an option for inoperable patients when per-
formed at expert medical centers. The expert consensus
advises tricuspid valve repair to be performed liberally dur-
ing left-sided cardiac surgery.6 For patients with primary
TR, surgery should be recommended in those with severe
dysfunction undergoing left-sided valve surgery, and con-
sidered in patients with moderate dysfunction undergoing
left-sided valve surgery. Surgery is recommended similarly
in patients with severe secondary TR undergoing left-sided
valve surgery. Surgery can be considered in patients with
mild or moderate secondary TR associated with a dilated
annulus undergoing left-sided valve surgery. Surgery is no
longer recommended in patients undergoing left-sided
valve surgery with mild or moderate TR and right-heart
failure in the absence of annular dilatation, which is a sig-
nificant change from the 2017 ESC/EACTS guidelines.
The expert consensus provides new recommendations for
patients not scheduled for left-sided surgery. Patients with
severe secondary TR should be considered for surgery if they
are symptomatic or have RV dilatation. Patients who have
undergone left-sided surgery and present with severe second-
ary TR and RV dilatation are regarded as high risk and should
be treated even if asymptomatic. However, surgical candidates
should be evaluated carefully for severe RV/LV dysfunction
or severe pulmonary vascular disease. The benefit of surgery
in such patients is not well-established. Thresholds of RV dys-
function for nonsurgical candidates also are not yet character-
ized. The current guidelines do not comment specifically on
the surgical candidacy of the patients with mild or moderate
secondary TR not scheduled for left-sided surgery. Expert con-
sensus recommends the surgery to be considered “early” in
symptomatic patients, leaving it to a provider to determine the
surgical candidacy on an individual basis.
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809
The expert consensus offers mostly unchanged recommen-
dations regarding the repair of isolated primary TR. Symptom-
atic patients with severe isolated primary TR should undergo
surgery if there is no severe RV dysfunction. Asymptomatic
patients with severe isolated primary TR and RV dilatation
should be considered for surgery. The current guidelines do
not comment on the thresholds of RV dilatation for surgical
candidates. Indications for surgical intervention can be found
in Table 8.
Conclusion
The 2021 European Society of Cardiology/European Asso-
ciation for Cardio-Thoracic Surgery updated guidelines on
the management of valvular heart disease are highly pertinent
to clinical practice, and the expert consensus should be
applauded for providing needed guidance in a dynamic field.
Pertinent changes to the 2021 guideline include, but are not
limited to, broadened definition of severe aortic stenosis
from Vmax >5.5 m/s to either Vmax >5.0 m/s or mean gradi-
ent 60 mmHg, intervening in asymptomatic severe aortic
stenosis when associated with LVEF <55%, a specific age
threshold of 75 years when considering SAVR versus TAVI,
and an LV end-diastolic diameter cutoff of 65 mm to diag-
nose aortic regurgitation. Additionally, atrial fibrillation
alone can be considered an independent risk factor for devel-
oping tricuspid regurgitation. Also, transcatheter tricuspid
repair is mentioned for the first time as a viable option for
inoperable patients. Tricuspid regurgitation surgery is no lon-
ger recommended in patients undergoing left-sided valve sur-
gery with mild-to-moderate TR and right-heart failure in the
absence of annular dilation. Mitral valve repair over replace-
ment continues to be preferred. The guidelines provide ample
supportive evidence for their key recommendations. It is
important to emphasize that deviation from the expert con-
sensus, within reason, may be needed to individualize care
based on practitioner judgment, institutional preference, and
patient goals of care.
Conflict of Interest
None.
References
1 Osnabrugge RL, Mylotte D, Head SJ, et al. Aortic stenosis in the elderly:
Disease prevalence and number of candidates for transcatheter aortic valve
replacement: A meta-analysis and modeling study. J Am Coll Cardiol
2013;62:1002–12.
2 Coffey S, Cairns BJ, Iung B. The modern epidemiology of heart valve dis-
ease. Heart 2016;102:75–85.
3 Grimard BH, Larson JM. Aortic stenosis: Diagnosis and treatment. Am
Fam Physician 2008;78:717–24.
4 Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for
the management of valvular heart disease. Eur Heart J 2022;43:561–632.
5 Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the
management of valvular heart disease. Eur Heart J 2017;38:2739–91.
6 Mohananey D, Aljadah M, Smith AAH, et al. The 2020 ACC/AHA guide-
lines for management of patients with valvular heart disease: Highlights
810 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811
and perioperative implications. J Cardiothorac Vasc Anesth 2022;36:
1467–76.
7 Vollema EM, Sugimoto T, Shen M, et al. Association of left ventricular
global longitudinal strain with asymptomatic severe aortic stenosis: Natu-
ral course and prognostic value. JAMA Cardiol 2018;3:839–47.
8 Baron SJ, Magnuson EA, Lu M, et al. Health status after transcatheter ver-
sus surgical aortic valve replacement in low-risk patients with aortic steno-
sis. J Am Coll Cardiol 2019;74:2833–42.
9 Iung B, Armoiry X, Vahanian A, et al. Percutaneous repair or medical
treatment for secondary mitral regurgitation: Outcomes at 2 years. Eur J
Heart Fail 2019;21:1619–27.
10 Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbid-
ity of aortic regurgitation in clinical practice. A long-term follow-up study.
Circulation 1999;99:1851–7.
11 Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for
evaluation of the severity of native valvular regurgitation with two-dimen-
sional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16:
777–802.
12 Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the
management of infective endocarditis: The Task Force for the Manage-
ment of Infective Endocarditis of the European Society of Cardiology
(ESC). Endorsed by: European Association for Cardio-Thoracic Surgery
(EACTS), the European Association of Nuclear Medicine (EANM). Eur
Heart J 2015;36:3075–128.
13 Keane MG, Pyeritz RE. Medical management of Marfan syndrome. Circu-
lation 2008;117:2802–13.
14 Garg P, Swift AJ, Zhong L, et al. Assessment of mitral valve regurgitation
by cardiovascular magnetic resonance imaging. Nat Rev Cardiol 2020;
17:298–312.
15 Dziadzko V, Dziadzko M, Medina-Inojosa JR, et al. Causes and mecha-
nisms of isolated mitral regurgitation in the community: Clinical context
and outcome. Eur Heart 2019;40:2194–202.
16 Antoine C, Benfari G, Michelena HI, et al. Clinical outcome of degenera-
tive mitral regurgitation: Critical importance of echocardiographic
quantitative assessment in routine practice. Circulation 2018;138:
1317–26.
17 Grigioni F, Clavel MA, Vanoverschelde JL, et al. The MIDA Mortality
Risk Score: Development and external validation of a prognostic model
for early and late death in degenerative mitral regurgitation. Eur Heart J
2018;39:1281–91.
18 Zilberszac R, Heinze G, Binder T, et al. Long-term outcome of active sur-
veillance in severe but asymptomatic primary mitral regurgitation. JACC
Cardiovasc Imaging 2018;11:1213–21.
19 Penicka M, Vecera J, Mirica DC, et al. Prognostic implications of magnetic
resonance-derived quantification in asymptomatic patients with organic
mitral regurgitation: Comparison with Doppler echocardiography-derived
integrative approach. Circulation 2018;137:1349–60.
20 Jung JC, Jang MJ, Hwang HY. Meta-analysis comparing mitral valve
repair versus replacement for degenerative mitral regurgitation across all
ages. Am J Cardiol 2019;123:446–53.
21 Lazam S, Vanoverschelde JL, Tribouilloy C, et al. Twenty-year outcome
after mitral repair versus replacement for severe degenerative mitral regur-
gitation: Analysis of a large, prospective, multicenter, international regis-
try. Circulation 2017;135:410–22.
22 Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused
update of the 2014 AHA/ACC guideline for the management of patients
with valvular heart disease: A report of the American College of Cardiol-
ogy/American Heart Association Task Force on Clinical Practice Guide-
lines. J Am Coll Cardiol 2017;70:252–89.
23 Mick SL, Keshavamurthy S, Gillinov AM. Mitral valve repair versus
replacement. Ann Cardiothorac Surg 2015;4:230–7.
24 Feldman T, Kar S, Elmariah S, et al. Randomized comparison of percuta-
neous repair and surgery for mitral regurgitation: 5-year results of EVER-
EST II. J Am Coll Cardiol 2015;66:2844–54.
25 Acker MA, Jessup M, Bolling SF, et al. Mitral valve repair in heart failure:
Five-year follow-up from the mitral valve replacement stratum of the
Acorn randomized trial. J Thorac Cardiovasc Surg 2011;142:569–74;574.
e561.
Descargado para Anonymous User (n/a) en CES University de ClinicalKey.es por Elsevier en marzo 30, 2023. Para uso personal
exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
26 Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter Mitral-valve
repair in patients with heart failure. N Engl J Med 2018;379:2307–18.
27 Pibarot P, Delgado V, Bax JJ. MITRA-FR vs. COAPT: Lessons from 2 tri-
als with diametrically opposed results. Eur Heart J Cardiovasc Imaging
2019;20:620–4.
28 Asch FM, Grayburn PA, Siegel RJ, et al. Echocardiographic outcomes
after transcatheter leaflet approximation in patients with secondary
mitral regurgitation: The COAPT trial. J Am Coll Cardiol
2019;74:2969–79.
29 Iung B, Vahanian A. Epidemiology of acquired valvular heart disease. Can
J Cardiol 2014;30:962–70.
30 Hajar R. Rheumatic fever and rheumatic heart disease a historical perspec-
tive. Heart Views 2016;17:120–6.
31 Negi PC, Kandoria A, Asotra S, et al. Gender differences in the epidemiol-
ogy of Rheumatic Fever/Rheumatic heart disease (RF/RHD) patient popu-
lation of hill state of northern India; 9 years prospective hospital based,
HP-RHD registry. Indian Heart J 2020;72:552–6.
32 Kingue S, Ba SA, Balde D, et al. The VALVAFRIC study: A registry of
rheumatic heart disease in Western and Central Africa. Arch Cardiovasc
Dis 2016;109:321–9.
33 Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for
the management of patients with valvular heart disease: Executive sum-
mary: A report of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines. Circulation
2021;143:e35–71.
34 Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of
valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc
Echocardiogr 2009;22:1–23;quiz 101-2.
35 Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects, aetiol-
ogy and natural history of acquired mitral valve stenosis. Eur Heart J
1991;12(Suppl B):55–60.
36 Kim HJ, Cho GY, Kim YJ, et al. Development of atrial fibrillation in
patients with rheumatic mitral valve disease in sinus rhythm. Int J Cardio-
vasc Imaging 2015;31:735–42.
37 Kim JY, Kim SH, Myong JP, et al. Outcomes of direct oral anticoagulants
in patients with mitral stenosis. J Am Coll Cardiol 2019;73:1123–31.
38 Karthikeyan G, Connolly SJ, Ntsekhe M, et al. The INVICTUS rheumatic
heart disease research program: Rationale, design and baseline characteris-
tics of a randomized trial of rivaroxaban compared to vitamin K antago-
nists in rheumatic valvular disease and atrial fibrillation. Am Heart J
2020;225:69–77.
39 Bruce CJ, Nishimura RA. Newer advances in the diagnosis and treatment
of mitral stenosis. Curr Probl Cardiol 1998;23:125–92.
40 Gaasch WH, Folland ED. Left ventricular function in rheumatic mitral ste-
nosis. Eur Heart 1991;12(Suppl B):66–9.
41 Iung B, Cormier B, Ducimetiere P, et al. Immediate results of percutaneous
mitral commissurotomy. A predictive model on a series of 1514 patients.
Circulation 1996;94:2124–30.
42 Nunes MC, Tan TC, Elmariah S, et al. The echo score revisited: Impact of
incorporating commissural morphology and leaflet displacement to the pre-
diction of outcome for patients undergoing percutaneous mitral valvulo-
plasty. Circulation 2014;129:886–95.
43 Badheka AO, Shah N, Ghatak A, et al. Balloon mitral valvuloplasty in the
United States: A 13-year perspective. Am J Med 2014;127:1126.;e1-1126.
e12.
44 Okura H, Nakada Y, Nogi M, et al. Prevalence of mitral annular calcifica-
tion and its association with mitral valvular disease. Echocardiograph
2021;38:1907–12.
45 Wang DD, Guerrero M, Eng MH, et al. Alcohol septal ablation to prevent
left ventricular outflow tract obstruction during transcatheter mitral valve
replacement: First-in-man study. JACC Cardiovasc Interv 2019;12:1268–79.
46 Sud K, Agarwal S, Parashar A, et al. Degenerative mitral stenosis: Unmet
need for percutaneous interventions. Circulation 2016;133:1594–604.
47 Chorin E, Rozenbaum Z, Topilsky Y, et al. Tricuspid regurgitation and
long-term clinical outcomes. Eur Heart J Cardiovasc Imaging 2020;
21:157–65.
 C.C. Welker et al. / Journal of Cardiothoracic and Vascular Anesthesia 37 (2023) 803811 811

48 Topilsky Y, Maltais S, Medina Inojosa J, et al. Burden of tricuspid regurgi-
tation in patients diagnosed in the community setting. JACC Cardiovasc
Imaging 2019;12:433–42.
49 Ortiz-Leon XA, Posada-Martinez EL, Trejo-Paredes MC, et al. Under-
standing tricuspid valve remodelling in atrial fibrillation using three-
dimensional echocardiography. Eur Heart J Cardiovasc Imaging 2020;
21:747–55.
50 Anvardeen K, Rao R, Hazra S, et al. Prevalence and significance of tricus-
pid regurgitation post-endocardial lead placement. JACC Cardiovasc
Imaging 2019;12:562–4.
51 Prihadi EA, van der Bijl P, Gursoy E, et al. Development of significant tri-
cuspid regurgitation over time and prognostic implications: New insights
into natural history. Eur Heart J 2018;39:3574–81.
52 Park JB, Lee SP, Lee JH, et al. Quantification of right ventricular volume
and function using single-beat three-dimensional echocardiography: A val-
idation study with cardiac magnetic resonance. J Am Soc Echocardiogr
2016;29:392–401.
53 Song JM, Jang MK, Choi YS, et al. The vena contracta in functional tricus-
pid regurgitation: A real-time three-dimensional color Doppler echocardi-
ography study. J Am Soc Echocardiogr 2011;24:663–70.
54 Hahn RT, Zamorano JL. The need for a new tricuspid regurgitation grading
scheme. Eur Heart J Cardiovasc Imaging 2017;18:1342–3.
55 Miura M, Alessandrini H, Alkhodair A, et al. Impact of massive or torren-
tial tricuspid regurgitation in patients undergoing transcatheter tricuspid
valve intervention. JACC Cardiovasc Interv 2020;13:1999–2009.
56 Peri Y, Sadeh B, Sherez C, et al. Quantitative assessment of effective
regurgitant orifice: Impact on risk stratification, and cut-off for severe and
torrential tricuspid regurgitation grade. Eur Heart J Cardiovasc Imaging
2020;21:768–76.
57 Stocker TJ, Hertell H, Orban M, et al. Cardiopulmonary hemodynamic
profile predicts mortality after transcatheter tricuspid valve repair in
chronic heart failure. JACC Cardiovasc Interv 2021;14:29–38.
58 Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure: The Task Force
for the diagnosis and treatment of acute and chronic heart failure of the
European Society of Cardiology (ESC). Developed with the special contri-
bution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail
2016;18:891–975.
59 Utsunomiya H, Itabashi Y, Mihara H, et al. Functional tricuspid regurgitation
caused by chronic atrial fibrillation: A real-time 3-dimensional transesopha-
geal echocardiography study. Circ Cardiovasc Imaging 2017;10:e004897.
60 Dhoble A, Zhao Y, Vejpongsa P, et al. National 10-year trends and out-
comes of isolated and concomitant tricuspid valve surgery. J Cardiovasc
Surg (Torino) 2019;60:119–27.
61 Taramasso M, Benfari G, van der Bijl P, et al. Transcatheter versus medi-
cal treatment of patients with symptomatic severe tricuspid regurgitation. J
Am Coll Cardiol 2019;74:2998–3008.
62 Montalto C, Sticchi A, Crimi G, et al. Functional and echocardiographic
improvement after transcatheter repair for tricuspid regurgitation: A sys-
tematic review and pooled analysis. JACC Cardiovasc Interv 2020;
13:2719–29.

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