2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS). Expert Consensus Systems of Care Documents are intended to summarize the position of these partnering organizations on the availability, delivery, organization, and quality of cardiovascular care, with the intention of establishing appropriate benchmarks. These Systems of Care Documents are overseen by the ACC Task Force on Health Policy Statements and Systems of Care. With the rapid evolution and dissemination of transcatheter technologies, as well as advances in surgical repair and valve replacement techniques, there is an imperative for the cardiovascular community to establish the provider, institutional, and systems-based standards for delivery of high-quality valvular heart disease (VHD) care. The AATS, ACC, ASE, SCAI, and STS have, therefore, joined together to provide expert consensus and, wherever feasible, evidence-based recommendations for systems of care related to VHD, in the spirit of ensuring access to quality outcomes. The writing group anticipates that future updates to this consensus statement will be necessary as newer imaging and treatment technologies become available and more data are generated regarding patient outcomes, cost, and cost-effectiveness. Dharam J. Kumbhani, MD, SM, FACC. Chair, ACC Task Force on Health Policy Statements and Systems of Care. In the past decade, the evaluation and management of patients with VHD has changed dramatically. Advances in noninvasive imaging have enabled reliable, reproducible, and objective measurements of valve disease severity, along with an appreciation of any associated hemodynamic and structural consequences. There is enhanced understanding of the natural history of VHD based upon longitudinal studies of large numbers of patients that have correlated outcomes with noninvasive measurements as well as with data obtained during exercise testing. Advances in surgical techniques, especially those associated with valve repair; improved operative results; and perioperative management strategies have contributed substantially to better patient outcomes. Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients with symptomatic, severe aortic stenosis (AS) and now provides a less-invasive treatment option for many eligible patients. Transcatheter repair of mitral regurgitation (MR) with an edge-to-edge clip device occupies a specific treatment niche currently, and more options for this valve lesion are anticipated in the near future. Transcatheter mitral valve replacement (TMVR) is the subject of intense investigation, and tricuspid valve interventions in high-surgical-risk patients are being developed. Collectively, these advances have led to an increasing number of treatment options, lower thresholds for and earlier timing of intervention, and the provision of less-invasive therapies to an older, sicker, and more frail population.1, 2 As the number and complexity of VHD treatment options have expanded, expert clinical judgment from an experienced multidisciplinary team (MDT) has assumed increasing importance. The number of patients with significant VHD who could benefit from appropriate intervention increases as a function of age. The elderly are the fastest growing segment of the U.S. population. 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