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In line with recent U.S. recommendations, the newest European guidelines favor a wider pool of patients eligible for surgical and transcatheter interventions for valvular heart disease.

For example, transcatheter edge-to-edge repair (e.g., the MitraClip procedure) is upgraded from a class IIb to a IIa procedure for secondary mitral regurgitation patients who are symptomatic despite guideline-directed medical therapy. This move was based on the COAPT report from 2018, though guideline authors acknowledged the negative MITRA-FR trial from the same year.

The new valvular disease guidelines by the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) were presented at the ESC virtual meeting and published online in . The last iteration of this document was .

"The use of surgery and transcatheter techniques as complementary treatment options has substantially increased the number of patients with aortic stenosis and mitral regurgitation undergoing interventions in the past decade," said guideline writing committee chair Alec Vahanian, MD, of the University of Paris, France, in an ESC press release.

In the new recommendations, more people can now undergo a valve-correcting procedure earlier -- based not on symptoms but imaging criteria.

In severe aortic regurgitation, for instance, surgery has a revised class I recommendation for asymptomatic patients with a left ventricular end-systolic diameter (LVESD) measuring more than 50 mm or a resting ejection fraction not exceeding 50%. A weaker class IIb recommendation is also provided for asymptomatic people with LVESD or ejection fraction abnormalities that don't reach these thresholds.

Aortic valve intervention is also granted a new class IIa recommendation for asymptomatic individuals with severe aortic stenosis and ejection fractions under 55%. This means transcatheter aortic valve replacement (TAVR) is also indicated where surgery had previously been the only procedural option, observed Michael Mack, MD, of Baylor Scott & White Health System in Plano, Texas.

He commented that the new ESC and EACTS guideline is "largely concordant" with recommendations from the American College of Cardiology and American Heart Association with few exceptions.

One notable difference between the European and U.S. guidelines is how to choose the mode of intervention in aortic stenosis, Mack said: the Europeans say TAVR versus surgery should be based on an age cut-off of 75 and higher risk on the EuroSCORE scale, instead of age over 80 alone as the threshold for TAVR being the clear choice stateside.

Vahanian and colleagues also moved bioprostheses from class IIa to class I status.

In turn, the group deemed transcatheter mitral and tricuspid valve-in-valve implantation, in cases of a failed surgical bioprosthesis, worthy of consideration in high-risk patients -- the first time this class IIb recommendation has been made.

Despite the attention on valve procedures, the new ESC guideline also highlighted advances in medical therapy.

Direct oral anticoagulants were explicitly recommended over vitamin K antagonists in multiple indications, including stroke prevention in people with native valve disease and atrial fibrillation.

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