Weekly Blog: The new 2014 ACC Valvular Heart Disease Guidelines

Some of the updates were reviewed at the rounds this week.

You can find the guidelines here.

The figures are particularly helpful in determining when to consider valve surgery.
AS
AR
MS
MR

Here are a few things in terms of surgery for aortic stenosis:

• The use of directly supervised exercise testing is recommended for asymptomatic patients with severe disease without symptoms to identify if they have symptoms, hypotension, or markedly increased gradients with exercise.
• Surgery is best considered in a "center of excellence" with a low rate of complications
• "TAVR is not recommended in patients with 1) a life expectancy of <1 year, even with a successful procedure, and 2) those with a chance of “survival with benefit” of <25% at 2 years."

 Here are a few things I found interesting about endocarditis:

1) They actually point out the harm in a pet peeve of mine -- premature antibiotics in suspected endocarditis:

"The leading cause of “culture-negative IE,” which can be a significant clinical conundrum, is the use of antibiotics before blood cultures are obtained. Negative blood cultures in the setting of IE can delay diagnosis by slowing other serological and polymerase chain reaction assessments; therefore, it can delay definitive treatment of the patient as well as impair determination of antimicrobial treatment duration"

2)  The RCT data for surgery in IE with a vegetation and valve dysfunction made it into the guidelines:

"Class IIb 
Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with NVE who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon)(655,788,789). (Level of Evidence: B)"

3) They abdicate the decision on antibiotics to previous guidelines.  Alas, there will be no AMP/CTX for enterococcus in a guideline yet.  It is coming!