31 August 2021
The European Association for Cardio-Thoracic Surgery (EACTS) and European Society of Cardiology (ESC) Guidelines for the management of valvular heart disease were published online in the European Journal of Cardio-Thoracic Surgery on Saturday 28th of August 2021.
EACTS is proud of this collaborative joint guideline, including all members of the Heart Team. A discussion within the Heart Team should be the basis of all treatment decisions. This recommendation should be discussed with the patient, who can then make an informed decision.
We recognise there is considerable interest in the use of age cut-offs to assist in the choice of intervention for aortic stenosis. The evidence favours SAVR in some patients, TAVI in others, and either mode of intervention can be used for those in between. The Heart Team discussion is central in the care of these patients, and the guideline (table 6) details the clinical, anatomical and procedural factors that influence the choice of treatment modality for an individual patient.
Randomised controlled trials comparing SAVR to TAVI have included patients based on estimated risk, not age, and there has been no evidence of interaction between age and outcomes. Life expectancy for an individual patient is difficult to estimate; it varies widely across the world and is dependent on absolute age, sex, frailty, and the presence of comorbidities. Age was chosen as surrogate, considering the interplay between estimated life expectancy and prosthetic heart valve durability.
Despite the lack of evidence for age in determining intervention modality, it has been used in several other recent recommendations. The 2017 ESC/EACTS valvular heart disease guidelines already proposed an age limit of 75 as cut-off (in table 7). The ACC/AHA 2020 guidelines recommend TAVR >80, SAVR <65 and a Heart Team discussion for patients in between. The German Cardiology and Cardiac Surgery Associations’ consensus statement proposes SAVR for low-risk patients ≤70, TAVI for patients ≥75, and a Heart Team discussion for patients in between. The age cut-offs agreed-upon in the ESC/EACTS guidelines can be considered conservative in comparison and were the subject of intense and constructive discussions. As there are no new data regarding age since the 2017 ESC/EACTS guideline, the same age of 75 years was used as in the previous iteration.
The guidelines have advanced other areas. Increased experience and procedural safety have led to expanded indications toward earlier surgery in asymptomatic patients with aortic stenosis, aortic regurgitation and mitral regurgitation. Furthermore, these joint guidelines inaugurated the contribution of a methodology group. We are encouraged to expand the use of this group to all guidelines and putting into place an open process, with independent review of the evidence using validated tools such as the GRADE system, and avoiding conflicts of interest.
We look forward to a continuing fruitful collaboration on these joint guidelines with our colleagues from ESC, advancing a common European perspective on the evidence. These guidelines should be a living document, updated as new data is made available with longer follow-up, particularly in the low-risk trials.
A video summary of advances in these guidelines can be seen on ESC TV (https://www.youtube.com/watch?v=Gb85wvcbWBs), as well as the live session at ESC Congress (for registered users: https://bit.ly/3DuIQCC). A session with Heart Team members of the Taskforce will provide insight during the 35th EACTS Annual Meeting in Barcelona on October 14th
Rafael Sádaba, EACTS Secretary General
Friedhelm Beyersdorf, Chair of the EACTS Task Force for the ESC/EACTS Guidelines on Heart Valve Disease
