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Chest pain overview

2022-11-08T09:22:28Z

Sara Zand: /* Overview */

__NOTOC__
{{Chest pain}}
{{CMG}}{{AE}} {{Sara.Zand}} {{Aisha}},{{nuha}}
==Overview==

After [[injuries]], [[chest pain]] is the second most common cause of seeking medical attention in [[emergency department]] ([[ED]]) in the [[United States]] and responsible for >6.5 million visits, which is 4.7% of all [[ED ]] visits. [[Chest pain]] also is the cause of nearly 4 million [[outpatient]] visits every year in the [[United States]]. [[Chest pain]] remains a diagnostic challenge in the [[ED]] and [[outpatiet]] setting and needs thorough [[clinical]] evaluation. Causes of [[chest pain]] include [[noncardiac]],and cardiac in which noncardiac [[chest pain]] is responsible for more than half of [[ED]] visits and only 5.1% will have an [[acute coronary syndrome]]. [[Coronary artery disease]] ([[CAD]]) is the leading cause of [[death]] for [[men]] and [[women]]. Distinguishing between serious and benign causes of [[chest pain]] is important. [[Chest pain]] is the most [[symptom]] of [[CAD]] in both [[men]] and [[women]].

==Historical Perspective==
The first recorded description of chest pain was given by Benivieni, a Florentine physician in the early 1500s. The first concise account of angina pectoris was given by the then Earl of Clarendon when he described his father's illness. Angina pectoris was described by a medical practitioner when Dr. William Heberden read his paper to the College of Physicians in London on 21 July 1768.

==Classification==
[[Chest pain]] traditionally has been classified into [[typical]] and atypical types. [[Chest pain]] that is more likely associated with [[ischemia]] includes substernal [[chest discomfort]] aggravated by [[exertion]] or [[emotional stress]] and relieved by [[rest]] or [[nitroglycerin]]. [[Ischemic chest discomfort]] can be described based on [[quality]], [[location]], [[radiation]], and provoking and relieving factors. Using the term of [[atypical chest pain]] is problematic. Although the term of atypical [[chest pain]] was intended to describe [[angina]] without typical [[chest]] [[symptoms]], it is more often used to consider that the [[symptom]] is [[noncardiac]] in origin. Then, it is discouraged using the term of atypical [[chest pain]]. Notably, [[chest pain]] is a broadly term to define referred [[pain]] in the [[shoulders]], [[arms]], [[jaw]], [[neck]], and upper [[abdomen]]. So, using the terms of [[cardiac]], possible [[cardiac]], and [[noncardiac]] are encouraged to describe the suspected causes of [[chest pain]].

==Pathophysiology==
The [[cardiovascular]] system, respiratory system, part of the [[gastrointestinal]] system, and the great [[vessels]] give off afferent visceral input via common [[thoracic]] [[autonomic ganglia]]. Painful stimuli in any of the aforementioned systems are usually sensed as originating from the [[chest]]. However, due to the fact that [[afferent nerve]] fibers overlap in the dorsal ganglia, pain in the [[thorax]] may be experienced at any point between the [[umbilicus]] and the [[ear]], as well as in the upper [[limbs]].

==Causes==
There are many [[organ]] systems, that when affected, can lead to the symptoms of [[chest pain]].The most common organs involved are the [[heart]], [[lungs]], and the [[digestive system]]. [[Psychiatric disorders]], can also lead to the perception of [[chest pain]]. The most important facet of diagnosis is distinguishing the life-threatening causes of [[chest pain]], to the more benign causes. [[Life-threatening]] causes of chest pain include [[myocardial infarction]], [[aortic dissection]], [[pulmonary embolism]], [[tension pneumothorax]], and [[esophageal rupture]]. Other common causes of chest pain include [[GERD]], chest wall tenderness, [[achalasia]], [[pneumonia]], and [[anxiety]].

==Differentiating Chest pain from Other Diseases==
There are several life-threatening causes of chest pain which need to be evaluated for first, which include; [[myocardial infarction]], [[aortic dissection]], [[esophageal rupture]], [[pulmonary embolism]], and [[tension pneumothorax]]. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.
==Epidemiology and Demographics==
There is a significant difference in the [[epidemiology]] of [[chest pain]] in the [[outpatient]] and [[emergency]] settings. The [[incidence]]<nowiki/> of [[chest pain]] is approximately 1,500 per 100,000 individuals worldwide. According to a study conducted in Belgium, the prevalence of [[chest pain]] is approximately 2000-5000 per 100,000 individuals worldwide. The incidence of patients presenting with chest pain increases with age and men are more likely to present with chest pain than women.

==Risk Factors==
Common [[risk factors]] in the development of chest pain may be associated with the [[cardiac]], [[Respiratory system|respiratory]], or [[Gastrointestinal tract|gastrointestinal]] systems. Other [[risk factors]] include [[smoking]], [[obesity]], [[drug abuse]], and [[psychiatric disorders]].

==Screening==
There is insufficient evidence to recommend routine screening for chest pain

==Natural History, Complications, and Prognosis==
[[Angina pectoris]] is defined as a retrosternal [[chest discomfort]] that increases gradually in intensity (over several [[minutes]]). Percipitant factors are [[physical]] or [[emotional]] [[stress]]. In [[ACS]], [[chest pain]] may occur during [[rest]]. [[Chest pain]] is characterized by [[radiation]] ([[ left arm]], [[neck]], [[jaw]]) and its associated [[symptoms]] ([[ dyspnea]], [[nausea]], [[lightheadedness]]). When actively treated or spontaneously resolving, it disappears over a few [[minutes]]. Relief with [[nitroglycerin]] is not necessarily a diagnostic criterion of [[myocardial ischemia]], especially because other causes such as [[esophageal spasm]] may have respons to [[nitroglycerin]]. Associated [[symptoms]] such as [[shortness of breath]], [[nausea]] or [[vomiting]], [[lightheadedness]], [[confusion]], [[presyncope]] or [[syncope]], or [[vague]] [[abdominal]] symptoms are more frequently seen among [[patient]]s with [[diabetes]], [[women]], and the [[elderly]]. A detailed assessment of [[cardiovascular]] [[risk factors]], review of [[systems]], [[past medical history]], and [[family]] and [[social history]] should be done in [[patients]] with [[chest pain]]. It is pivotal to identify and triage the [[patients]] presented with [[chest pain]] within 10 minutes of arrival to the [[hospital]]. [[Patients]] diagnosed with [[STEMI]] should be scheduled for primary [[PCI]]. Early recognition of [[STEMI]] may improve [[outcomes]]. [[Stable angina]] and non-cardiac [[chest pain]] should be evaluated in [[outpaient]] setting.
Common [[complications]] of chest pain include [[arrythmia]], [[heart failure]] and Death. Depending on the etiology at the time of presentation, the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as good.

==[[Chest Pain]] in [[Pregnancy]]==
Causes of chest pain in pregnancy are similar to those in the general population. Acute life-threatening causes include [[ST elevation myocardial infarction in pregnancy|myocardial infarction]], [[aortic dissection]], [[tension pneumothorax]], as well as [[thromboembolic]] diseases that are more common in [[pregnancy]] such as [[pulmonary embolism]] and [[amniotic fluid embolism]]. Occasionally, [[chest pain]] in [[pregnant]] [[women]] is caused by physiological changes in [[pregnancy]], namely [[chest expansion]] and [[breast]] tenderness.

==Diagnosis==
===Diagnostic Study of Choice===
[[Chest pain]] or [[chest pain]] equivalent may be referred as [[chest pain]]. Diagnosis of nontraumatic [[chest pain]] is frequent challenge for [[physicians]]. Initial evaluation is considered for life-threatening [[conditions]] such as [[ACS]], [[aortic dissection]], and [[pulmonary embolism ]], as well as nonvascular syndromes (eg, [[esophageal rupture]], [[tension pneumothorax]]). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, [[chest pain]] usually reflects a more benign [[condition]]. The initial work-up is taking [[ECG]], but exact [[history]], [[physical examination]], [[biomarkers]], and other tests are necessary. There is no association between the intensity of [[symptoms]] and [[seriousness]] of [[disease]] and general similarity of [[symptoms]] among different causes of [[chest pain]]. A [[comprehensive]] [[history]] with all characteristics of [[chest pain]] including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated [[symptoms]] should be obtained to identify the underlying causes of [[chest pain]].

===History and Symptoms===
The patient's history must be thoroughly investigated to exclude the life-threatening causes of [[chest pain]], such as the [[cardiovascular]] ones: [[acute coronary syndrome]], [[aortic dissection]], [[pulmonary embolism]] but also the non-cardiac such as [[tension pneumothorax]] and [[esophageal rupture]]. [[Chest pain]] in [[myocardial ischemia]] presented as deep, difficult to localization, and diffuse. Point tenderness is less likely to be [[symptom]] of [[myocardial ischemia]]. [[Chest pain]] characterized by [[duration]], [[provoking factors]], [[relieving factors]], [[age]], [[cardiac risk factors]]. [[Patient]] [[history]] is the most important basis of defining [[myocardial ischemia]]. Because of complexity of [[cardiac symptoms]] and variable expression of [[chest pain]], [[ischemic chest pain]] may be present as non-[[cardiac]] [[chest pain]].[[Characteristic]] of [[chest pain]] with high likelihood of [[myocardial ischemia]] including: central, [[pressure]], [[squeezing]], [[gripping]], [[heaviness]], [[tighness]], [[exertional]], [[stress related]], [[retrosternal]], [[left-sided]], [[dull]], [[aching]], [[Characteristic]] of [[chest pain]] with less likelihood of [[myocardial ischemia]] include [[right-sided]], [[tearing]], [[ripping]], [[burning]], [[sharp]], [[fleeting]], [[shifting]], [[pleuritic]], [[positional]].

===Physical Examination===

[[Physical examination]] should focus on evaluating for the life-threatening causes of chest pain first. A complete physical exam should be done, which includes a thorough [[cardiac]], [[lung]], and [[abdominal]] exam.

===Laboratory Findings===
Serial [[troponin]]s and [[CK-MB]] should be ordered. Additional laboratory tests include [[serum electrolytes]], a [[complete blood count]], [[renal function tests]], and [[liver function tests]].

===Electrocardiogram===
The key findings to look for on an [[ECG]] is the [[ST elevation]] which is characteristic of [[myocardial infarction]]. However, The major challenge is the differential between [[NSTE-ACS]] and non-cardiac [[chest pain]]. Diffuse [[ST elevation]] may point to the [[diagnosis]] of [[pericarditis]]. A serial [[ECG]] should be obtained to evaluate for continued or progression of [[myocardial]] injury over time.

===X-ray===
[[Chest X-ray]] can be useful in the initial evaluation of the patient to ascertain if there is [[cardiomegaly]], [[pulmonary edema]] and [[aortic dissection]]. [[Computed tomography|CT scanning]] may be better for visualizing the etiology of chest pain depending on the patient history and their symptoms.

===Echocardiography and Ultrasound===
[[Transthoracic echocardiography]] ([[TTE]]) can be helpful for diagnosis the causes of acute [[chest pain]] such as acute [[aortic dissection]], [[pericardial effusion]], [[stress cardiomyopathy]], and [[ hypertrophic cardiomyopathy]]. In addition, [[TTE]] does provide information for patients with acute [[chest pain]] and suspected [[ACS]] about left and [[right ventricular function]] and [[regional wall motion abnormalities]]. [[Stress echocardiography]] can be used to define [[ischemia]] severity and for risk stratification purposes when ≥2 contiguous segments of [[wall motion abnormalities]] in [[coronary territories]] are visualized.

===CT scan===
[[Coronary CT angiography]] ([[CCTA]]) can be helpful to diagnose the extent and severity of [[nonobstructive]] and [[obstructive]] [[CAD]], as well as high-risk features of [[atherosclerotic plaque]] (positive [[remodeling]], [[low attenuation plaque]]). [[ Fractional flow reserve]] with [[CT]] ([[FFR-CT]]) provides additional information about [[ischemia]] related to [[lesion]]. Dosimetry is low for [[CCTA]], with effective doses for most patients in the 3 to 5 mSv range.

===MRI===
[[Cardiovascular magnetic resonance imaging]] ([[CMR]]) is helpful to accurately determin global and regional left and [[right ventricular]] function, localized [[myocardial ischemia]] and [[infarction]], and detection of [[myocardial viability]]. [[Myocardial edema]] and [[microvascular obstruction]] can be determined by [[CMR]] to differentiate acute versus chronic [[MI]], as well as other causes of acute [[chest pain]], including [[myocarditis]].

===Other Imaging Findings===
After ruling out of [[ACS]], rest/stress [[positron emission tomography]] ([[PET]]) or [[single-photon emission computed tomography]] ([[SPECT]]) [[myocardial perfusion imag-ing]] ([[MPI]]) are helpful for detection of [[perfusion]] abnormalities, measures of [[left ventricular]] function, and high-risk findings, such as [[transient ischemic dilation]]. For [[PET]], calculation of [[myocardial blood flow reserve]] ([[MBFR]], the ratio of peak [[hyperemia]] to [[resting myocardial blood flow]]) adds diagnostic and [[prognostic]] information over [[MPI]]. [[Radiation]] exposure dose is ∼3 mSv for rest/stress [[PET]] with [[Rb]]-82 and ∼10 mSv for [[Tc-99m SPECT]].

===Other Diagnostic Studies===
[[Invasive Coronary Angiography]] ([[ICA]]) is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]], including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]]. [[ICA]] provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or [[surgical revascularization]]. ([[IFR]] and [[FFR]]) provide [[physiologic]] characteristic of stenosis. [[Radiation]] exposure to the [[patient]] during an [[interventional procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity. The spatial resolution of [[ICA]] is 0.3 mm, so, visualization of [[arterioles]] (diameter of 0.1 mm) that regulate [[ myocardial blood flow]] is impossible. [[Coronary vascular functional]] studies can be performed during [[coronary angiography]]. In normal [[ coronary angiography]] there may be evident abnormal [[coronary vascular function]]. Assessment of [[coronary microcirculation]] and [[coronary vasomotion]] by [[coronary function testing]] are reasonable.

==Treatment==
===Medical Therapy===
A correct diagnosis of the underlying cause of the [[chest pain]] should be obtained prior to deciding on an appropriate treatment strategy. The most dangerous causes should be evaluated first. If [[myocardial infarction]] or [[ischemia]] is suspected, the immediate pharmacotherapies including [[morphine]], [[oxygen]], [[nitrate]], [[aspirin]], [[ACE inhibitors]] should be initiated.

===Interventions===
Common indications of [[coronary angiography]] in high risk [[ACS]] [[patients]] include new [[ischemic]] changes on the [[ECG]], [[troponin]]-confirmed acute [[myocardial injury]], new-onset [[left ventricular systolic dysfunction ]] ([[ejection fraction]] <40%), and newly diagnosed moderate-severe [[ischemia]] on [[stress]] imaging. For high-risk [[patients]] presented with documented [[AMI]] and normal [[epicardial coronary arteries]] on [[CCTA]] or invasive [[ coronary angiography]], or nonobstructive [[CAD]], [[CMR]] and [[echocardiography]] are useful for evaluation of [[nonischemic cardiomyopathy]] or [[myocarditis]]. Among high risk [[patients]], [[invasive coronary angiography]] provides a comprehensive assessment of the extent and severity of obstructive [[CAD]]. The determination of the severity of anatomic [[CAD]] is critical to guide the use of [[coronary revascularization]]. Approximately 6% to 15% of [[troponin]]-positive [[ACS]] occurs in the absence of obstructive [[CAD]]. Additional testing may be helpful to determine the strategy of treatment. Evidence supports that [[CMR]] can identify [[wall motion abnormalities]] and [[myocardial edema]] and distinguish [[infarct]]-related [[scar]] from non-[[CAD]] causes such as [[myocarditis]] and [[nonischemic cardiomyopathy]]. Performing [[CMR]] within 2 weeks of [[ACS]], can be useful to identify [[MI ]] with nonobstructive [[CAD]] ([[MINOCA]]) from other causes. The term obstructive [[CAD]] indicates [[CAD]] with ≥50% stenosis. Nonobstructive [[CAD]] is used if [[CAD]] <50% stenosis. High risk [[CAD]] is defined in the presence of obstructive [[stenosis]] with [[left main]] stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis).

===Surgery===
Common causes of acute [[chest pain]] in the months after [[CABG]] include [[musculoskeletal]] pain from [[sternotomy]]( the most common cause), [[myocardial ischemia]] from acute [[graft stenosis]] or [[occlusion]], [[pericarditis]], [[pulmonary embolism]], [[sternal]] [[wound]] [[infection]] , nonunion. [[Post-sternotomy pain syndrome]] is defined as discomfort after [[thoracic]] [[surgery]], persisting for at least 2 months, and without apparent cause. The [[incidence]] of [[post-sternotomy pain syndrome]] is varied 7%-66% with a higher [[prevalence]] in [[women]] compared with [[men]] within the first 3 months of [[thoracic surgery]] but, after 3 months, [[postoperative]] [[sex]] difference in [[prevalence]] was not seen. Causes of [[ Graft]] failure within the first year post-[[CABG]] using [[saphenous venous grafts]] are technical issues, [[intimal hyperplasia]], [[thrombosis]]. [[Internal mammary artery graft]] failure within the first-year post-[[CABG]] is most commonly attributable to issues with the [[anastomotic site]] of the [[graft]]. Causes of acute [[chest pain]] several years after [[CABG]] include [[graft]] stenosis, occlusion or progression of [[disease]] in a non-bypassed [[vessel]]. One year after [[CABG]], about 10%-20% of [[saphenous vein grafts]] fail. By 10 years, about half of [[saphenous vein grafts]] are patent. The [[internal mammary artery]] has patency rates of 90% to 95% 10 to 15 years after [[CABG]]. The use of [[radial artery grafts]] for [[CABG]] has a higher patency rate at 5 years of follow-up, compared with the use of [[saphenous vein grafts]].

===Primary Prevention===
Make healthy lifestyle choices to prevent chest pain from heart disease: Achieve and maintain normal weight, Control high blood pressure, high cholesterol, and diabetes, avoid cigarette smoking and secondhand smoke, eat a diet low in saturated and hydrogenated fats and cholesterol, and high in starches, fiber, fruits, and vegetables, get at least 30 minutes of moderate intensity exercise on most days of the week, Reduce stress.

===Secondary Prevention===
[[Secondary prevention]] of [[chest pain]] depends on the cause for instance, risk factor modification remains essential part of the [[secondary prevention]] strategy in [[chronic stable angina]]. [[Secondary prevention]] of [[chest pain]] caused by [[GERD]] is avoiding [[food ]] that worsens the symptoms, [[smoking]] cessation, [[weight loss]], eating frequent [[meals]], and head raising of the bed while [[sleeping]].

==References==
{{Reflist|2}}

[[Category:Cardiology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Gastroenterology]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T09:36:53Z

Sara Zand: /* Prevention */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==[[Sudden cardiac death]] victim==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.
 
'''Abbreviations:'''
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''PVC:''' [[Premature ventricular complex]];
'''VF:''' [[Ventricular fibrillation]];
'''VT:''' [[Ventricular fibrillation]];

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]] 
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
for [[ICD]], [[catheter ablation]] may be considered when an [[ICD]] is not available, contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
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{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T09:33:37Z

Sara Zand: /* Prevention */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==[[Sudden cardiac death]] victim==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.
 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]] 
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
for [[ICD]], [[catheter ablation]] may be considered when an [[ICD]] is not available, contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T09:32:08Z

Sara Zand: /* Prevention */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==[[Sudden cardiac death]] victim==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]] 
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
for [[ICD]], [[catheter ablation]] may be considered when an [[ICD]] is not available, contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sandbox:Sara.Zand

2022-09-16T09:30:57Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

==secondary prevention of sudden cardiac death==
==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]] 
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
for [[ICD]], [[catheter ablation]] may be considered when an [[ICD]] is not available, contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T07:57:13Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

==secondary prevention of sudden cardiac death==
==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]] 
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
for [[ICD]], catheter ablation may be considered
when an ICD is not available, contraindicated for
concurrent medical reasons, or declined by the
patient.
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sudden cardiac death post arrest care and prevention

2022-09-16T07:27:18Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==[[Sudden cardiac death]] victim==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T07:26:11Z

Sara Zand: /* Post cardiac arrest survivors */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T07:24:52Z

Sara Zand: /* Consensus and CMS Indications for ICD Placement */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
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{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
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{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sandbox:Sara.Zand

2022-09-16T07:20:11Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T07:13:22Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]] 
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T07:12:42Z

Sara Zand: /* SUDDEN CARDIAC DEATH VICTIM */

==SUDDEN CARDIAC DEATH VICTIM==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority 
❑In cases of [[sudden death]], it is recommended to collect a detailed description of circumstances of [[death]], [[symptoms]] prior to [[death]], the [[family history]], and
to review prior [[medical]] files 
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]]
❑In cases of [[SCD]], it is recommended to retain samples suitable for [[DNA]] extraction and consult with [[cardiac]] [[pathologist]] when an inherited cause is suspected or the cause of death unexplained 
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]] 
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended 
❑Following [[SADS]] ([[sudden arrhythmic death syndrome]]), post-mortem [[genetic]] testing targeted to [[primary electrical disease]] is recommended when the [[decedent]] is young (,50) and/or the circumstances and/or [[family history]] support a primary electrical disease 
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T06:18:10Z

Sara Zand: /* post cardiac arrest survivors */

==SUDDEN CARDIAC DEATH VICTIM==
==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sudden cardiac death post arrest care and prevention

2022-09-16T06:12:58Z

Sara Zand: /* Post cardiac arrest survivors */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Consensus and CMS Indications for [[ICD]] Placement====
The following are clear Grade 1 A or CMS supported recommendations for placement of an [[ICD]]:
* Based upon the MADIT II study entry criteria, [[patients]] with a prior [[MI]] and an [[LVEF]] of < 30% should be treated with an [[ICD]] after 40 days. This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Based upon the [[SCD]]-Heft study entry criteria, [[patients]] with [[ischemic cardiomyopathy]] who are symptomatic with NYHA grade II or III [[CHF]] with an [[LVEF]] < 35%. Again, This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Some [[patients]] will not have an [[LVEF]] as low as < 30% as in MADIT II or as low as an [[LVEF]] < 35% as in SCD-HeFT, but if they have an [[LVEF ]]< 40%, and nonsustained [[ventricular tachycardia]] on [[Holter monitoring]] and are inducible on [[EP testing]], then they are appropriate candidates for [[ICD placement]] based upon the MUSTT and MADIT I trials.
* Based upon the MADIT I study entry criteria, [[patients]] with a history of [[MI]] with an [[LVEF]] < 35% who have inducible [[VT]] or [[VF]] on [[electrophysiologic testing]] at least 4 weeks after [[STEMI]].
* [[Patients]] who meet the COMPANION criteria who have an indication for a [[cardiac resynchronization]] ([[CRT]]) device and have NYHA class IV [[congestive heart failure]] ([[CHF]])

====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T06:12:22Z

Sara Zand: /* Post cardiac arrest survivors */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
'''Abbreviations:'''
'''CIEDs:''' [[Cardiac insertable electronic devices]];
'''CMR:''' [[Cardiac magnetic resonance]];
'''CT:''' [[Computed tomography]];
'''ECG:''' [[Electrocardiogram]];
'''LGE:''' [[Late gadolinium enhancemen]];
'''SCA:''' [[Sudden cardiac arrest]];
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
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{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
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{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
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{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
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{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
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{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
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{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
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===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Consensus and CMS Indications for [[ICD]] Placement====
The following are clear Grade 1 A or CMS supported recommendations for placement of an [[ICD]]:
* Based upon the MADIT II study entry criteria, [[patients]] with a prior [[MI]] and an [[LVEF]] of < 30% should be treated with an [[ICD]] after 40 days. This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Based upon the [[SCD]]-Heft study entry criteria, [[patients]] with [[ischemic cardiomyopathy]] who are symptomatic with NYHA grade II or III [[CHF]] with an [[LVEF]] < 35%. Again, This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Some [[patients]] will not have an [[LVEF]] as low as < 30% as in MADIT II or as low as an [[LVEF]] < 35% as in SCD-HeFT, but if they have an [[LVEF ]]< 40%, and nonsustained [[ventricular tachycardia]] on [[Holter monitoring]] and are inducible on [[EP testing]], then they are appropriate candidates for [[ICD placement]] based upon the MUSTT and MADIT I trials.
* Based upon the MADIT I study entry criteria, [[patients]] with a history of [[MI]] with an [[LVEF]] < 35% who have inducible [[VT]] or [[VF]] on [[electrophysiologic testing]] at least 4 weeks after [[STEMI]].
* [[Patients]] who meet the COMPANION criteria who have an indication for a [[cardiac resynchronization]] ([[CRT]]) device and have NYHA class IV [[congestive heart failure]] ([[CHF]])

====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T06:04:55Z

Sara Zand: /* Post Arrest Care and prevention */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post [[cardiac arrest]] survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
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{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Consensus and CMS Indications for [[ICD]] Placement====
The following are clear Grade 1 A or CMS supported recommendations for placement of an [[ICD]]:
* Based upon the MADIT II study entry criteria, [[patients]] with a prior [[MI]] and an [[LVEF]] of < 30% should be treated with an [[ICD]] after 40 days. This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Based upon the [[SCD]]-Heft study entry criteria, [[patients]] with [[ischemic cardiomyopathy]] who are symptomatic with NYHA grade II or III [[CHF]] with an [[LVEF]] < 35%. Again, This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Some [[patients]] will not have an [[LVEF]] as low as < 30% as in MADIT II or as low as an [[LVEF]] < 35% as in SCD-HeFT, but if they have an [[LVEF ]]< 40%, and nonsustained [[ventricular tachycardia]] on [[Holter monitoring]] and are inducible on [[EP testing]], then they are appropriate candidates for [[ICD placement]] based upon the MUSTT and MADIT I trials.
* Based upon the MADIT I study entry criteria, [[patients]] with a history of [[MI]] with an [[LVEF]] < 35% who have inducible [[VT]] or [[VF]] on [[electrophysiologic testing]] at least 4 weeks after [[STEMI]].
* [[Patients]] who meet the COMPANION criteria who have an indication for a [[cardiac resynchronization]] ([[CRT]]) device and have NYHA class IV [[congestive heart failure]] ([[CHF]])

====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sudden cardiac death post arrest care and prevention

2022-09-16T06:03:45Z

Sara Zand: /* Role of Electrophysiology Testing */

__NOTOC__
{{Sudden cardiac death}}
{{CMG}} {{AE}} {{Sara.Zand}}

See also [[Post cardiac arrest syndrome care pathway]]

==Overview==
Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline. [[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]] in patients with [[ischemic heart disease]] and [[ICD]] implantation in patients with reduced [[left ventricular ejection fraction]] who had an experience of lethal [[arrhythmia]].
The optimal approach to prevention of [[SCD]] following [[ST-elevation MI]] ([[STEMI]]) has been evaluated in multiple randomized trials. In general, [[post-STEMI]] [[patients ]]should be treated with evidence-based therapies that have been associated with a reduction in [[SCD]] including [[beta-blockers]], [[ACE-inhibitors]] (or [[ARB]]s in [[patients]] who are [[ACEI]] intolerant) and [[statins]]. In [[patients]] who have symptomatic [[congestive heart failure]] ([[CHF]]), an [[aldosterone antagonist]] may be a reasonable additional therapy. Despite the intuitive benefits of [[antiarrhythmic]], [[amiodarone]] and [[sotalol]] have not been shown to reduce all-cause [[mortality]] following [[STEMI]], although [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with [[ICD]]s who have unacceptably high rates of [[shock]]. In general terms, [[ICD placement]] is indicated in those [[patients]] with a reduced [[left ventricular]] [[ejection fraction]] at 40 days [[post-MI]] and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the survival benefits in this population.

==Post Arrest Care and prevention==

=== Prevention ===

*Effective measures for the [[primary prevention]] of [[sudden cardiac death]] in individuals who are at risk of [[SCD]] but have not yet experienced an aborted [[cardiac arrest]] or [[life-threatening arrhythmias]] include [[ICD]] implantation based on the guideline.<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
*[[Secondary prevention]] strategy following aborted sudden cardiac death include [[revascularization]], [[ICD]] implantation.

==2017AHA/ACC/HRS Guideline for management of [[sudden cardiac arrest]] and [[ventricular arrhythmia]]==
'''Abbreviations:'''
'''MI:''' [[Myocardial infarction]];
'''VT:''' [[Ventricular tachycardia]];
'''VF:''' [[Ventricular fibrillation]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''ICD:''' [[Implantable cardioverter defibrillator]];
'''NYHA:''' [[New York Heart Association]] functional classification;
'''LVAD:''' [[Left ventricular assist device]];
'''EPS:''' [[Electrophysiology study]]

 

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for primary prevention of sudden cardiac death in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]]≤ 35% and [[NYHA]] class 2,3 [[heart failure]] despite medical therapy, at least 40 days post [[MI]] or 90 days post [[revascularization]] with life expectancy > 1 year 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD]] implantation ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[LVEF]] ≤ 40% and nonsustained [[VT]] due to prior [[MI]] or [[VT]] ,[[VF]] inducible in [[EPS]] with life expectancy >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[ICD implantation]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In patients with [[NYHA]] class 4 who are candidates for cardiac transplantation or [[LVAD]] with life expectancy > 1 year
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[ICD ]] is not beneficial in patients with [[NYHA]] class 4 despite optimal medical therapy who are not candidates for [[cardiac transplantation]] or [[LVAD]]
|-
|}

'''Abbreviations:'''
'''IHD:''' [[Ischemic heart disease]];
'''VT:''' [[Ventricular tachycardia]];
'''SCD:''' [[Sudden cardiac death]];
'''SCA:''' [[Sudden cardiac arrest]];
'''ICD:''' [Implantable cardioverter defibrillator[]];
'''EPS:''' [[Electrophysiologic study]]

 

{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | A01=Secondary prevention in patients with [[IHD]]}}
{{Family tree | | | | |,|-|-|^|-|-|.| | }}
{{Family tree | | | | B01 | | | | B02 | | |B01=[[SCA]] survivor or sustained monomorph [[VT]]|B02=Cardiac [[syncope]]}}
{{Family tree | | | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | | C01 | | | | C02 |-|-|-|.| | | | | |C01=[[Ischemia]]|C02=LVEF≤35%}}
{{Family tree | | |,|-|^|-|.| | | | | | | | |!| | | |}}
{{Family tree | | |D01| |D02| | | | | | |!| | | | | | | |D01=Yes: [[revascularization]], reassessment about [[SCD]] risk (class1)|D02=NO:[[ICD]] candidate}}
{{Family tree | | | | |,|-|^|-|.| | | | |,|-|^|-|.| |}}
{{Family tree | | | | |E01| |E02| | | D03 | | D04 | | | | E01=Yes:[[ICD]] (class1)|E02=NO: medical therapy (class1)|D03= Yes:[[ICD]] (CLASS1)| D04=NO:[[EP study]] (class 2a)}}
{{Family tree | | | | | | | | | | | | | | | | | |!| |}}
{{Family tree | | | | | | | | | | | | | | | | | E03 | |E03=[[Ventriculat arrhythmia]] induction}}
{{Family tree | | | | | | | | | | | | | | | |,|-|^|-|.| |}}
{{Family tree | | | | | | | | | | | | | | | |F01| |F02| |F01=Yes: [[ICD]] (class1)|F02=NO: monitoring }}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

===Timing of [[Sudden Cardiac Death]] Following [[ST-elevation MI]] ===
[[Patients]] with [[STEMI]] are at risk of s[[udden cardiac death]]. The timing of [[sudden cardiac death]] following [[STEMI]] is as follows:
* In the first 3 months after [[STEMI]], one-quarter of [[sudden cardiac deaths]] occur. This statistic is critical in so far as [[implantable cardiac defibrillators]] are often not implanted in the first three months. It is for this reason that wearable [[defibrillators]] are sometimes used in patients with a large [[MI]] and reduced [[ejection fraction]].
* In the first year following [[STEMI]], one-half of the [[sudden cardiac deaths]] occur.
* Beyond one year, there is still an increased risk of [[sudden cardiac death]] for a prolonged period of time.

===Medical Therapy to Prevent Sudden Death Following STEMI===

*Therapies aimed to reduce disease progression, stabilize plaque, improve [[left ventricular function]], and reduce [[ischemia]] may minimize the risk of [[sudden cardiac death]]. These therapies include [[beta blockade]], [[ACE inhibition]], and [[statins]].

====[[Beta Blockers]]====

*[[Beta blocker]] administration has been associated with a reduction in [[sudden cardiac death]]. <ref name="pmid10688573">{{cite journal | author = Nuttall SL, Toescu V, Kendall MJ | title = beta Blockade after myocardial infarction. Beta blockers have key role in reducing morbidity and mortality after infarction | journal = [[BMJ (Clinical Research Ed.)]] | volume = 320 | issue = 7234 | pages = 581 | year = 2000 | month = February | pmid = 10688573 | pmc = 1117610 | doi = | url = http://bmj.com/cgi/pmidlookup?view=long&pmid=10688573 | issn = | accessdate = 2011-02-06}}</ref>. The reduction in SCD was greatest among patients with [[congestive heart failure]].
*Among patients with an [[ICD]], [[beta blocker]] administration has been associated with an additional reduction in mortality in MADIT II and a lower frequency of [[ICD]] discharge <ref name="pmid16125497">{{cite journal | author = Brodine WN, Tung RT, Lee JK, Hockstad ES, Moss AJ, Zareba W, Hall WJ, Andrews M, McNitt S, Daubert JP | title = Effects of beta-blockers on implantable cardioverter defibrillator therapy and survival in the patients with ischemic cardiomyopathy (from the Multicenter Automatic Defibrillator Implantation Trial-II) | journal = [[The American Journal of Cardiology]] | volume = 96 | issue = 5 | pages = 691–5 | year = 2005 | month = September | pmid = 16125497 | doi = 10.1016/j.amjcard.2005.04.046 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(05)00942-2 | issn = | accessdate = 2011-02-06}}</ref>.

====[[ACE Inhibitor]]====
*[[ACE inhibitor]] administration has been associated with reduction in the risk of [[SCD]].<ref name="pmid10080457">{{cite journal | author = Domanski MJ, Exner DV, Borkowf CB, Geller NL, Rosenberg Y, Pfeffer MA | title = Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials | journal = [[Journal of the American College of Cardiology]] | volume = 33 | issue = 3 | pages = 598–604 | year = 1999 | month = March | pmid = 10080457 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(98)00609-3 | issn = | accessdate = 2011-02-06}}</ref> .

====Angiotensin II Receptor Blockers (ARBs)====
*If a patient is intolerant to [[ACE inhibitor]], an [[ARB]] can be administered.
*[[Valsartan]] is non-inferior to [[captopril]] in reducing [[post MI mortality]], and may therefore confer similar benefits in [[SCD]] <ref name="pmid14610160">{{cite journal | author = Pfeffer MA, McMurray JJ, Velazquez EJ, Rouleau JL, Køber L, Maggioni AP, Solomon SD, Swedberg K, Van de Werf F, White H, Leimberger JD, Henis M, Edwards S, Zelenkofske S, Sellers MA, Califf RM | title = Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both | journal = [[The New England Journal of Medicine]] | volume = 349 | issue = 20 | pages = 1893–906 | year = 2003 | month = November | pmid = 14610160 | doi = 10.1056/NEJMoa032292 | url = http://dx.doi.org/10.1056/NEJMoa032292 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Statin]] Therapy====
*Among patients with an [[ICD]] implanted, [[statin]] administration has been associated with a reduction in documented [[arrhythmias]] [[post-MI]].<ref name="pmid12849664">{{cite journal | author = Mitchell LB, Powell JL, Gillis AM, Kehl V, Hallstrom AP | title = Are lipid-lowering drugs also antiarrhythmic drugs? An analysis of the Antiarrhythmics versus Implantable Defibrillators (AVID) trial | journal = [[Journal of the American College of Cardiology]] | volume = 42 | issue = 1 | pages = 81–7 | year = 2003 | month = July | pmid = 12849664 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0735109703004984 | issn = | accessdate = 2011-02-06}}</ref> <ref name="pmid17383296">{{cite journal | author = Dickinson MG, Ip JH, Olshansky B, Hellkamp AS, Anderson J, Poole JE, Mark DB, Lee KL, Bardy GH | title = Statin use was associated with reduced mortality in both ischemic and nonischemic cardiomyopathy and in patients with implantable defibrillators: mortality data and mechanistic insights from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) | journal = [[American Heart Journal]] | volume = 153 | issue = 4 | pages = 573–8 | year = 2007 | month = April | pmid = 17383296 | doi = 10.1016/j.ahj.2007.02.002 | url = http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(07)00122-6 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Aldosterone Antagonists]]====
*In the [[EPHESUS trial]], among the specific subgroup of post [[MI]] patients who have [[left ventricular]] dysfunction and / or [[diabetes]], [[eplerenone]] administration was associated with reduction in all cause and [[SCD]] mortality (4.9% vs 6.1%)<ref name="pmid12668699">{{cite journal | author = Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M | title = Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction | journal = [[The New England Journal of Medicine]] | volume = 348 | issue = 14 | pages = 1309–21 | year = 2003 | month = April | pmid = 12668699 | doi = 10.1056/NEJMoa030207 | url = http://dx.doi.org/10.1056/NEJMoa030207 | issn = | accessdate = 2011-02-06}}</ref>.

====[[Anti-arrhythmics]]====
*Despite the intuitive benefits of anti-arrhythmic treatments, [[antiarrhythmics]] have not shown a reduction in all-cause mortality in the management of post [[MI]] [[SCD]].
*[[Amiodarone]] was associated with a reduction in [[arrhythmic]] [[death]] among [[patients]] with an [[LVEF]] of <40% following [[STEMI]], but [[all cause mortality]] was not improved in the CAMIAT <ref name="pmid9078198">{{cite journal | author = Cairns JA, Connolly SJ, Roberts R, Gent M | title = Randomised trial of outcome after myocardial infarction in patients with frequent or repetitive ventricular premature depolarisations: CAMIAT. Canadian Amiodarone Myocardial Infarction Arrhythmia Trial Investigators | journal = [[Lancet]] | volume = 349 | issue = 9053 | pages = 675–82 | year = 1997 | month = March | pmid = 9078198 | doi = | url = http://linkinghub.elsevier.com/retrieve/pii/S0140673696081718 | issn = | accessdate = 2011-02-04}}</ref> <ref name="pmid10089841">{{cite journal | author = Farré J, Romero J, Rubio JM, Ayala R, Castro-Dorticós J | title = Amiodarone and "primary" prevention of sudden death: critical review of a decade of clinical trials | journal = [[The American Journal of Cardiology]] | volume = 83 | issue = 5B | pages = 55D–63D | year = 1999 | month = March | pmid = 10089841 | doi = | url = | issn = | accessdate = 2011-02-04}}</ref> trial.
*[[ Anti-arrhythmics]] such as [[amiodarone]] may be useful in reducing the frequency of [[shocks]] in [[patients]] with an [[ICD]] who have excessively frequent [[shocks]]. [[Flecainide]] and *[[propafenone]] should not be administered as these Class I C agents are [[proarrhythmic]] in [[patients]] with [[coronary artery disease]] <ref name="pmid1900101">{{cite journal | author = Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL | title = Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial | journal = [[The New England Journal of Medicine]] | volume = 324 | issue = 12 | pages = 781–8 | year = 1991 | month = March | pmid = 1900101 | doi = 10.1056/NEJM199103213241201 | url = http://dx.doi.org/10.1056/NEJM199103213241201 | issn = | accessdate = 2011-02-07}}</ref>.

===Induced [[Hypothermia]] to Improve [[Neurological]] Outcome===
<ref name="pmid16314375">{{cite journal| author=ECC Committee, Subcommittees and Task Forces of the American Heart Association| title=2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. | journal=Circulation | year= 2005 | volume= 112 | issue= 24 Suppl | pages= IV1-203 | pmid=16314375 | doi=10.1161/CIRCULATIONAHA.105.166550 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16314375 }} </ref>

*A [[systematic review]] by the [[Cochrane Collaboration]] suggests benefit.<ref name="pmid22972067">{{cite journal| author=Arrich J, Holzer M, Havel C, Müllner M, Herkner H| title=Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 9 | issue= | pages= CD004128 | pmid=22972067 | doi=10.1002/14651858.CD004128.pub3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22972067 }} </ref>
*A second [[systematic review]] focusing on survivors of [[non-shockable rhythms]] suggests benefit.<ref name="pmid21835145">{{cite journal| author=Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW| title=Does therapeutic hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomized and non-randomized studies. | journal=Resuscitation | year= 2012 | volume= 83 | issue= 2 | pages= 188-96 | pmid=21835145 | doi=10.1016/j.resuscitation.2011.07.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21835145 }} </ref>
*[[Patients]] surviving [[cardiac arrest]] who cannot follow commands or who are comatose may have increased chance of favorable [[neurological outcome]] if their [[body]] [[temperature]] is cooled to 32 to 34 degrees centigrade. <ref name="pmid11856793">{{cite journal| author=Hypothermia after Cardiac Arrest Study Group| title=Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 549-56 | pmid=11856793 | doi=10.1056/NEJMoa012689 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856793 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12207424 Review in: ACP J Club. 2002 Sep-Oct;137(2):46] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12402814 Review in: Evid Based Nurs. 2002 Oct;5(4):111] </ref> <ref name="pmid11856794">{{cite journal| author=Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al.| title=Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 8 | pages= 557-63 | pmid=11856794 | doi=10.1056/NEJMoa003289 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11856794 }} </ref>,

===Prevention of [[Sudden Death]] and [[Implantable Cardioverter Defibrillators]] Following [[STEMI]]===
* [[ICD]] placement is indicated in those patients with a reduced [[left ventricular ejection fraction]] at 40 days post-MI and/or 3 months following [[revascularization]] ([[PCI]] or [[CABG]]) for [[STEMI]] given the [[survival]] benefits in this population.
* [[Patients]] should also be treated with [[beta-blockers]], [[ACE inhibitors]], and [[statins]].
* Patients undergoing [[ICD]] implantation should not have a limited life expectancy due to non-[[cardiovascular]] causes.
====Consensus and CMS Indications for [[ICD]] Placement====
The following are clear Grade 1 A or CMS supported recommendations for placement of an [[ICD]]:
* Based upon the MADIT II study entry criteria, [[patients]] with a prior [[MI]] and an [[LVEF]] of < 30% should be treated with an [[ICD]] after 40 days. This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Based upon the [[SCD]]-Heft study entry criteria, [[patients]] with [[ischemic cardiomyopathy]] who are symptomatic with NYHA grade II or III [[CHF]] with an [[LVEF]] < 35%. Again, This is true whether or not the patient is inducible on [[electrophysiological]] testing.
* Some [[patients]] will not have an [[LVEF]] as low as < 30% as in MADIT II or as low as an [[LVEF]] < 35% as in SCD-HeFT, but if they have an [[LVEF ]]< 40%, and nonsustained [[ventricular tachycardia]] on [[Holter monitoring]] and are inducible on [[EP testing]], then they are appropriate candidates for [[ICD placement]] based upon the MUSTT and MADIT I trials.
* Based upon the MADIT I study entry criteria, [[patients]] with a history of [[MI]] with an [[LVEF]] < 35% who have inducible [[VT]] or [[VF]] on [[electrophysiologic testing]] at least 4 weeks after [[STEMI]].
* [[Patients]] who meet the COMPANION criteria who have an indication for a [[cardiac resynchronization]] ([[CRT]]) device and have NYHA class IV [[congestive heart failure]] ([[CHF]])

====Role of [[Electrophysiology]] Testing====
*Inducibiity and pharmacologic suppression of [[VT]]/[[VF]] on [[electrophysiologic]] studies is no longer deemed to be relevant based upon the [[MUSTT]] study <ref name="pmid10601507">{{cite journal | author = Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G | title = A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 341 | issue = 25 | pages = 1882–90 | year = 1999 | month = December | pmid = 10601507 | doi = 10.1056/NEJM199912163412503 | url = http://dx.doi.org/10.1056/NEJM199912163412503 | issn = | accessdate = 2011-02-06}}</ref> and the MADITT I study <ref name="pmid8960472">{{cite journal | author = Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine JH, Saksena S, Waldo AL, Wilber D, Brown MW, Heo M | title = Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators | journal = [[The New England Journal of Medicine]] | volume = 335 | issue = 26 | pages = 1933–40 | year = 1996 | month = December | pmid = 8960472 | doi = 10.1056/NEJM199612263352601 | url = http://dx.doi.org/10.1056/NEJM199612263352601 | issn = | accessdate = 2011-02-06}}</ref>.
*Importantly, lack of inducibility on [[electrophysiological]] testing should not preclude implantation of an [[ICD]].

===The Benefit of [[ICD]] Implantation May Be Greater in Patients with a [[QRS]] Duration > 120 msec===

*In both SCD-HeFT and MADIT II, the reduction in [[SCD]] was greater in patients with a [[QRS]] duration > 120 msec.

===Wearable [[Defibrillators]]===
In [[patients]] with a large [[MI]] with a low [[EF]] who are awaiting permanent [[ICD]] implantation, the use of a wearable [[defibrillator]] is a reasonable strategy.

===[[Cardiac resynchronization therapy]] ([[CRT]]) Combined with [[ICD]] Placement===
Based upon the results of the COMPANION trial it is reasonable to place a combined [[ICD ]]/ [[CRT]] device in [[patients]] with the following:
* Symptomatic NYHA Class III or IV congestive [[heart failure]]
* A [[left ventricular]] [[ejection fraction]] < 35%
* Evidence of [[left ventricular]] dyssynchrony with a [[QRS]] > 120 msec

==See also==

* [[Sudden cardiac death]]
* [[Sudden cardiac death post arrest care and prevention]]
* [[Post cardiac arrest syndrome care pathway]]
* [[Therapeutic hypothermia]]

==References==

{{reflist|2}}

{{WH}}
{{WS}}

Sandbox:Sara.Zand

2022-09-16T06:00:38Z

Sara Zand: /* post cardiac arrest survivors */

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Blood sample, ECG, Cardiac imaging ([[ESC guidelines classification scheme|Class I, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing 
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors 
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended 
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause 
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T05:48:30Z

Sara Zand: /* post cardiac arrest survivors */

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Brain and chect CT scan ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a [[hemodynamically]] tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Sandbox:Sara.Zand

2022-09-16T05:21:45Z

Sara Zand: /* vt storm */

==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== vt==

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==polymorphic vt==

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

==AS==
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}}
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}}
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}}
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}}
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}}
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}}
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}}
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}}
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }}
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}}
{{Family tree/end}}

==a1==
{{Family tree/start}}
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}}
{{Family tree| | | | | | |!| | | | | }}
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}}
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}}
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}}
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}}
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}}
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }}
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}}
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }}
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}}
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}}

{{Family tree/end}}

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[BAV]]
*Subaortic ([[LV outflow tract]]) calcification
*[[Rheumatic valve disease]]
*Small or large [[aortic]] annulus
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Mechanical or surgical [[bioprosthetic]] valve preferred
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Bioprosthetic]] valve preferred
*Favorable ratio of [[life expectancy]] to valve durability
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Aortic]] dilation
*Severe [[primary MR]]
*Severe [[CAD]] requiring [[bypass grafting]]
*[[Septal hypertrophy]] requiring [[myectomy]]
*[[AF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Irreversible severe [[LV systolic dysfunction]]
*Severe [[MR]] attributable to annular [[calcification]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Severe [[lung]], [[liver]], or [[rena]]l disease
*[[Mobility]] issues (high procedural risk with [[sternotomy]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Symptoms]] likely attributable to noncardiac [[conditions]]
*Severe [[dementia]]
*Moderate to severe involvement of ≥2 other [[organ]] systems
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[SAVR]] risk low
*[[TAVI]] risk high
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[TAVI]] risk low to medium
*[[SAVR]] risk high to prohibitive
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]]
*Vascular access does not allow [[transfemoral]] [[TAVI]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]]
*Previous [[chest irradiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]]
*[[Vascular access]] does not allow transfemoral [[TAVI]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Less uncertainty about valve durability
*Avoid repeat intervention
*Lower risk of [[permanent pacer]]
*[[Life]] prolongation
*[[Symptom]] relief
*Improved long-term [[exercise capacity]] and [[quality of life]]
*Avoid [[vascular]] complications
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Uncertainty about valve durability and possible repeat [[intervention]]
*Higher risk of [[permanent pacer]]
*Life prolongation
*[[Symptom]] relief
*Improved [[exercise capacity]] and [[quality of life]]
* Shorter [[hospital stay]], less postprocedural [[pain]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*[[Life prolongation]] not an important goal
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures
*Avoid procedural [[stroke]] risk
*Avoid possibility of [[cardiac pace maker implantation]]
|-

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]] 
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Mechanical [[aortic]] [[prothesis]] is preferred over [[bioprosthetic]] [[valve]] for [[patients]] < 50 years of age and no contraindication of [[anticoagulant therapy]] 
❑For [[patients]] 50-65 years of age without contraindication of [[anticoagulant]] therapy, choosing either [[mechanical]] or [[bioprothesis]] [[aortic]] [[valve]] should be individualized based on [[patient]] factors 
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For [[patients]] <50 years of age who desire bioprosthetic valve and appropriate anatomy, the [[Rose procedure]] including replacement of aortic valve by a [[pulmonic autograft]] may be considered
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}
'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]



{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year 
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability 
❑[[TAVI]] is recommended in symptomatic [[severe]] [[AS]] who are >80 years or younger [[patients]] with [[life expectancy]] <10 years and no anatomic contraindication for transfemoral [[TAVI]] 
❑ [[TAVI]] is recommended in symptomatic [[patients]] with severe [[AS]] in any age and high surgical risk or prohibitive for [[surgery]] when predicted [[survival]] is > 12 months after [[TAVI]] with acceptable [[quality of life]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in preference to [[TAVI]] in asymptomatic severe [[AS]] and abnormal [[exercise stress test]], very severe [[AS]], rapid progression, and [[elevated]] [[BNP]] 
❑ In [[asymptomatic]] [[severe]] [[AS]] in age ≤ 80 years of age and [[LVEF]] < 50 and no anatomic contraindications for transfemoral [[TAVI]], making decision between [[TAVI]] and [[SAVR]] is similar to [[symptomatic]] [[patients]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For symptomatic severe [[AS]] when predictive [[survival]] is <12 months after [[TAVI]] or [[SAVR]] and minimal improvement in [[quality of life]] is expected, [[palliative care]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ AHA guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For critically ill [[patients]] with severe [[AS]], percutaneous [[aortic ballon dilation]] is a bridge to [[TAVI]] or [[SAVR]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[cor

===b1===
{| class="wikitable" style="width: 80%; text-align: justify;"

! style="width:12%" | '''Class'''
! style="width:8%" | ''' Level'''
! style="width:80%" | '''Recommendations'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C || Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B-NR || Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C || Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.
|}

===c1===

{{Familytree/start}}
{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= [[Aortic Regurgitation]]}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | B02 | B02= Moderate [[Aortic Regurgitation]]>}}
{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03=Severe [[Aortic Regurgitation]] ❑VC>0.6cm ❑ [[Holodiastolic aortic flow reversal]] ❑ RVol≥60 ml ❑ RF≥ 50% ❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic (stage D) | C02=Asymptomatic (stage C) |C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]]) }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% AND ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² )| D05= ❑ Progressive decrese in [[LVEF]] to <55%-60% or increase in [[LVEDD]] to >65mm on at least 3 studies}}
{{Family tree | |!| | | |!| | | | | | | |!| | | |!| | | |!| | | | | | | | | | }}
{{Family tree | E01 | | E02 | | | | | | E04 | | E05 | | E| | | | | | | | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E=Low surgical risk}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | G| | G=[[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])}}
{{Family tree/end}}
'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter; '''VC:''' [[vena contracta]]; '''RVol:''' [[regurgitant volume]]; '''RF:''' [[regurgitant fraction]]; '''ERO:''' [[ effective regurgitant orifice]]
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===a1===
{{familytree/start}}
{{familytree | | | | | | | | | B01 | | | | | |B01=[[Tricuspid regurgitation]]}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | | | | | | | | |!| C01=Progressive [[TR]] (Stage B)| }}
{{familytree | | |!| | | | | | | | | | | | | |!| }}
{{familytree | | D01 | | | | | | | | | | | |D02|D01=At time of left sided [[valve]] [[surgery]]|D02=Severe [[TR]] (Stage C,D)}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=Annular dilation> 4 cm, or perior righ [[heart failure]] |E02=[[Asymptomatic]] (Stage C)|E03=At time of left sided [[valve]] [[surgery]]|E04=[[Right heart failure]] (Stage D)}}
{{familytree | | |!| | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | K | | | | | | | | | F01 | | F02 | | |!|F01= [[Primary TR]] with progressive [[RV]] dilation or [[systolic]] dysfunction |F02=[[TV]] [[surgery]] (1)|K=[[TV]] [[surgery]] (2a)}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | E1 | | | | | | | |!| | | | | | | | | | | | | E1=[[TV]] [[surgery]] (2b)| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N1| | | N2| | N3| | | | | | | | | | N1=[[Primary TR]]|N2=Prior [[left sided]] valve [[surgery]]|N3=[[Secondary TR]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | |L1 | | |G2 | |U1 | | | | | | | | | | |L1=[[TV]] [[surgery]] (2a)|G2=Absent of severe [[pulmonary hypertension]] or [[RV systolic dysfunction]] |U1=Poor response to [[medical therapy]] |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | |G3 | | | U2| | | | | | | | | | |G3=[[TV]] [[surgery]] (2b) |U2=Annular dilation without [[pulmonary hypertension]] or left sided [[disease]]|}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | U3| | | | | | | | | | | |U3=[[TV]] [[surgery]] (2a) |}}
{{familytree/end}}
'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adapted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===A===
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of prosthetic valve dysfunction'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical prosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with obstructive [[thrombosis]] who are critically ill [[patients]] without serious [[comorbidities]], urgent or emergency [[valve]] replacement is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Fibrinolysis]] (using [[recombinant tissue plasminogen activator]] 10 mg bolus + 90 mg in 90 min with [[UFH]] or [[streptokinase]] 1500 000 U in 60 min without [[UFH]]) should be considered when [[surgery]] is very high risk or is not available , or for [[thrombosis]] of right-sided [[prostheses]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered for large (>10 mm) non-obstructive prosthetic [[thrombus]] complicated by [[embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | '''Bioprosthetic thrombosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[bioprosthetic]] [[valve thrombosis]], [[anticoagulation]] using a [[VKA]] and/or [[UFH]] is recommended before considering re-intervention 
|-
|style="font-size: 100; padding: 0 5px; background: #FFC0CB" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] should be considered in [[patients]] with leaflet thickening and reduced [[leaflet]] motion causing elevated [[gradients]], at least until resolution 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | '''Hemolysis and paravalvular leak ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Reoperation is considered when a [[paravalvular]] leak is related to [[endocarditis]] or leading [[haemolysis]] requiring repeated [[blood transfusions]] or causes severe [[heart failure]] [[symptoms]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] closure is recommended for suitable paravalvular leaks with clinically significant [[regurgitation]] and/or [[haemolysis]] in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #AFEEEE" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] or [[surgical]] closure of clinically significant [[paravalvular]] leaks is considered based on [[patient]] risk status, leak morphology, and local [[expertise]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | '''Bioprosthetic failure ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation is recommended in [[symptomatic]] [[patients]] with severe [[regurgitation]] or a significant increase in [[transprosthetic gradient]] (after exclusion of valve [[thrombosis]]) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Desion of [[Transcatheter]], [[transfemoral]] valve-in-valve implantation in the [[aortic]] position should be considered by the [[Heart Team]] based on anatomic considerations, features of the [[prosthesis]], and high risk [[patients]] for [[surgery]] or [[inoperable]] [[patients]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Transcatheter]] [[valve-in-valve]] implantation in the [[mitral]] and [[tricuspid]] position may be considered in high risk [[patients]] for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Reoperation should be considered in [[asymptomatic]] [[patients]] with significant [[prosthetic dysfunction]] if reoperation is low risk 

|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]

 

===B===
{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= [[Antithrombotic]] therapy for [[valve prostheses]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= [[Mechanical heart valve]]| C02=[[Bioprosthetic heart valve]]|C02=[[Bioprosthetic heart valve]] }}
{{Family tree | |!| | | |,|-|-|V|-|-|-|.| | | | | | | | | | |}}
{{Family tree | C3 | |G1 | | G2| | G3| | | | | | | | | | |G1=[[MVR]]/[[TVR]] |C3=[[VKA]] lifelong (Class I) |G2=[[SAVR]]|G3=[[TAVI]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | | | | | |}}
{{Family tree | C4 | | | B1| | B1| | B1|-|-|-|.| | | | | | | | | |C4=[[CAD]] |B1=Other indications for oral [[anticoagulation]]}}
{{Family tree | |!| | | |,|^|-|.| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C6 | | H1| | H2|:| | | | | | | |:| | | | | | | | |C6=Add low-dose [[ASA]] in low risk [[patients]] for [[bleeding]] (Class IIb) |H1=NO|H2=Yes}}
{{Family tree | |!| | | |!| | |!| | |:| | | | | | | |:| | | | | | |}}
{{Family tree | C7 | |J1 | | J2|:| | | | | | | |:| | | | | | | | C7= [[Subtherapeutic]] [[INR]] for major planned invasive procedure |J1=[[OAC]] for 3 months (Class IIa)|J2=[[OAC]] long-term (Class I)}}
{{Family tree | |!| | | | | | | | | |:| | | | | | | |:| | | | | |}}
{{Family tree | C8 | | | | | | | |,|^|-|.| | | | | |:| | |C8=Bridging [[anticoagulation]] with [[UFH]] or [[LMWH]] (not required for minor [[surgeries]]) (Class I)}}
{{Family tree | | | | | | | | | |L1 | |L2 | | | |:| | | L1=NO|L2=Yes}}
{{Family tree | | | | | | | | | |!| | | |!| | | | | |:| | | |}}
{{Family tree | | | | | | | | | L3| | | L4| | |,|^|-|-|-|.| |L3=[[SAPT]] or [[OAC]] for 3 months (Class IIa)|L4=[[OAC]] long-term (Class I)}}
{{Family tree | | | | | | | | | | | | | | | | | |K1 | | | K2| | | | | |K1=NO|K2=Yes}}
{{Family tree | | | | | | | | | | | | | | | | | |!| | | | |!| | |}}
{{Family tree | | | | | | | | | | | | | | | | | |K3 | | |K4 | | | | K3=[[SAPT]] long-term (Class I)|K4=[[OAC]] long-term (Class I) |}}
{{Family tree/end}}

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ASA]]:''' [[acetylsalicylic acid]];
'''AF:''' [[Atrial fibrillation]];
'''CAD:''' [[Coronary artery disease]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''SAVR:'''[[Surgical aortic valve replacement]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]];
'''TVR:'''[[Tricuspid valve replacement]] or [[repair]];
'''MVR:'''[[Mitral valve replacement]] or [[repair]]

 

===C===

{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Management of antithrombotic therapy in the perioperative period ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑It is recommended discontinuation of [[VKA]] prior to [[elective surgery]] to aim for an [[INR]] <1.5 
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]] 
* [[AF]] with significant [[mitral stenosis]] 
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]] 
* Acute [[thrombotic]] event within the previous 4 weeks 
*High acute [[thrombotic]] risk 
❑In [[patients]] who have undergone [[valve]] surgery with an indication for [[postoperative]] therapeutic bridging, it is recommended to initiate either [[UFH]]
or [[LMWH]] 12-24 h after [[surgery]] 
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period 
❑In [[patients]] treated with [[DAPT]] after recent [[PCI]] (within 1 month) requiring [[heart valve]] [[surgery]] in the absence of an indication for
[[OAC]], starting the [[P2Y12 inhibitor]] postoperatively is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For bridging, therapeutic doses of either [[UFH]] or subcutaneous LMWH are recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Re-initiation of the [[VKA]] on the first [[postoperative]] day is recommended in [[patients]] with [[mechanical]] [[valve]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Concomitant antiplatelet therapy ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is low, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring long-term [[OAC]], early cessation (≤1 week) of [[aspirin]] and continuation of [[dual therapy]] with [[OAC]] and a [[P2Y12 inhibitor]] (preferably [[clopidogrel]]) for up to 6 months (or up to 12 months in [[ACS]]) is recommended 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑If the risk of [[stent thrombosis]] is high, in [[patients]] undergone [[PCI]] or after [[ACS]] requiring both [[OAC]] and [[antiplatelet therapy]], [[triple therapy]] with [[aspirin]], [[clopidogrel]] and [[OAC]] for longer than 1 week should be considered with the total duration (≤1 month) 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] with [[mechanical heart valve]] treated with a [[VKA]] and low risk for [[stent thrombosis]] and [[HAS-BLED]] ≥ 3 , [[clopidogrel]] alone should be considered
for up to 12 [[months]] 
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Surgical valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑For all [[patients]] with an [[mechanical heart valve]] prosthesis, [[OAC]] using a [[VKA]] is recommended lifelong 
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[biological heart valve]] and [[AF]], [[NOACs]] should be considered over [[VKA ]] after 3 months following surgical implantation 
❑ In [[patients]] with an [[aortic]] [[biological heart valve]], low-dose [[aspirin]] (75-100 mg/day) or [[OAC]] using a [[VKA]] should be considered for the first 3 months
after [[surgical]] implantation 
❑ In [[patients]] with a [[mitral]] or [[tricuspid]] [[biological heart valve]], [[OAC]] using a [[VKA]] should be considered for the first 3 months after [[surgical]] implantation 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[mechanical heart valve]] and evidence of [[atherosclerotic]] disease and low risk of [[bleeding]], The addition of low-dose [[aspirin]] (75-100 mg/
day) to [[VKA]] may be considered in selected [[patients]] 
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Low-dose [[aspirin]] (75-100 mg/day) in addition to [[VKA]] should be considered after [[thromboembolism]] despite an adequate [[INR]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[NOACs]] are not recommended in [[patients]] with a [[mechanical valve]] prosthesis 
|-
|style="font-size: 100; padding: 0 5px; background: #EEE8AA " align=left | '''Surgical valve repair ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] with [[VKA]] should be considered during the first 3 months after [[mitral]] and [[tricuspid repair]] 
❑[[SAPT]] with low-dose [[ASA]] (75-100 mg/day) should be considered for the first 3 months after [[valve]]-sparing [[aortic]] surgery when there are no
other baseline indications to 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | '''Transcatheter aortic valve replacement ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑[[OAC]] is recommended lifelong for [[TAVI]] [[patients]] who have other indications for [[OAC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑Lifelong [[SAPT]] is recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98 " align=left | ''' ([[ ESC guidelines classification scheme|Class III, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5 ; width: 70%" align=left|
❑ Routine use [[OAC]] is not recommended after [[TAVI]] in [[patients]] with no baseline indication for [[OAC]]
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[ACS]]:''' [[Acute coronary syndrome]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''DAPT:''' [[Dual antiplatelet therapy]];
'''INR:''' [[International normalized ratio]];
'''[[LMWH]]:''' [[Low molecular weight heparin]];
'''LV:''' [[Left ventricular]];
'''PCI:'''[[Percutaneous coronary intervention]];
'''[[OAC]]:'''[[Oral anticoagulation]];
'''SAPT:'''[[Single antiplatelet therap]];
'''UFH:''' [[Unfractionated heparin]];
'''VKA:'''[[Vitamin K antagonist]]

 

===D===

{| style="cellpadding=0; cellspacing= 0; width: 1200px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for prosthetiv valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''Mechanical protheses ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] is recommended according to the desire of the informed [[patient]] and NO contraindications to long term [[anticoagulation]] 
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] should be considered in [[patients]] already on [[anticoagulation]] because of a [[mechanical prosthesis]] in another [[valve]] position 
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A mechanical [[prosthesis]] should be considered in [[patients]] aged <60 years for [[prostheses]] in the [[aortic]] position and aged <65 years for [[prostheses]] in the [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #FFE4B5" align=left | '''([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' Biological prothesis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]] 
❑A [[bioprosthesis]] is recommended when [[anticoagulant theray]] is contraindicated because of high bleeding risk (previous major [[bleed]], [[comorbidities]], [[unwillingness]], [[adherence]] problems, [[lifestyle]], [[occupation]] and low [[life expectancy]] 
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] should be considered in [[patients]] for whom there is a low likelihood and/or a low operative risk of future redo [[valve]] surgery 
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]] 
❑A [[bioprosthesis]] should be considered in [[patients]] aged >65 years for a prosthesis in the [[aortic]] position or aged >70 years in a [[mitral]] position 
|-
|style="font-size: 100; padding: 0 5px; background: #98FB98" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]] 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];


 

===G===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in tricuspid valve disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Tricuspid stenosis ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] with severe [[tricuspid stenosis]] 
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe primary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Primary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with moderate primary [[tricuspid regurgitation]] undergoing [[left-sided valve]] [[surgery]] 
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] is recommended in [[patients]] with severe secondary [[tricuspid regurgitation]] undergoing left-sided valve surgery 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Surgery]] should be considered in [[patients]] with mild or moderate secondary [[tricuspid regurgitation]] with a dilated [[annulus]] (≥40 mm or >21 mm/m2 by 2D [[echocardiography]]) undergoing
left-sided valve [[surgery]] 
❑[[Surgery]] should be considered in [[patients]] with severe secondary [[tricuspid regurgitation]] (with or without previous left-sided [[surgery]]) who are
symptomatic or have [[RV]] dilatation, in the absence of severe [[RV]] or [[LV dysfunction]] and severe [[pulmonary vascular disease]]/ [[pulmonary hypertension]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Secondary Tricuspid Regurgitation ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Transcatheter]] treatment of symptomatic secondary severe [[tricuspid regurgitation ]] may be considered in inoperable [[patients]] 

|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

====F===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of clinically significant [[rheumatic]] [[mitral stenosis]] ([[MVA]] ≤ 1.5 cm2)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]] }}
{{Family tree | |,|-|-|^|-|-|-|.| }}
{{Family tree | C01 | | | | C02 | C01=NO| C02= Yes}}
{{Family tree | |!| | | | | | |!| | | | | | | | | | | }}
{{Family tree | | E | | | | | F | | | | | | | | | | | | F=Contraindication to [[PMC]]|E= High risk of [[embolism]] or [[hemodynamic]] decompensation}}
{{Family tree | |,|^|-|.| | | | |,|^|-|-|-|.| }}
{{Family tree | T | | S | | | H | | | G | |S=NO | T=Yes|H=NO|G=Yes}}
{{Family tree |!| | | |!| | | | |!| | | | |!| | | | | | |}}
{{Family tree | V | | U | | | J | | |I | | | | | | | |U=[[Exercise test]] |V= [[PMC]] if favourable characteristics for [[PMC]] or contraindication for [[surgery]]
* [[Surgery]] if unfavourable charactristics for [[PMC]]|I=[[Surgery]]|J=Contraindication or high risk for [[surgery]]}}
{{Family tree | | | | |!| | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | |W | | | |K | | L | | | W=[[Symptoms]]|K=Yes| L=NO |}}
{{Family tree | | |,|^|-|.| | | | |!| | | | |!| | | | | | |}}
{{Family tree | | X | | Y | | | M | | | N | | | | X=NO|Y=Yes|M=[[PMC]]|N=Favourable [[anatomical]] [[characteristics]] |}}
{{Family tree | |!| | | | | |!| | | | | | |,|^|-|-|-|.| | | |}}
{{Family tree | |Z1 | |Z2 | | | | | | | O | | |P | | | O=NO| Z2=Contraindication to or unfavourable characteristics for [[PMC]]| Z1=[[Follow-up]]|P=Yes}}
{{Family tree | | | |,|-|^|-|.| | | | | | |!| | | | |!| | | | | | | }}
{{Family tree | | | |Z3 | |Z4 | | | | | Q | | |R | | | Q=[[Surgery]]|Z4=Yes |Z3=NO |R=[[PMC]]}}
{{Family tree | | | |!| | | |!| | | | | | | | | | | |}}
{{Family tree | | | |Z5 | |Z6 | | | | | | | | | | | | |Z6=[[Surgery]] |Z5=[[PMC]] }}
{{Family tree/end}}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]

 

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===K===

{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]]
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] 
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and:
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]]) 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;

 

*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
*[[MVA]] >1.5 cm²
*[[Left atrial]] [[thrombus]]
*More than mild [[mitral regurgitation]]
*Severe or bi-commissural [[calcification]]
*Absence of [[commissural fusion]]
*Severe concomitant [[aortic valve]] disease, or severe combined [[tricuspid stenosis]] and [[tricuspid regurgitation]] requiring [[surgery]]
*Concomitant [[coronary artery disease ]] requiring [[bypass surgery]]

===P===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | | H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N | | | | |Y=Yes=[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}

{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''MV:'''[[Mitral valve]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVAD:''' [[Left ventricular assist devices]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]];
'''CAD:''' [[Coronary artery disease]]

 

===T===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]] 
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]] 

|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[symptomatic]] inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]] 
❑In high-risk symptomatic [[patients]] not eligible for [[surgery]] and low likelihood of responding to [[TEER]], making decision about [[TEER]] procedure or other transcatheter [[valve]] therapy and evaluation for [[ventricular assist device]] or [[heart transplant]] should be considered 
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

'''Abbreviations:'''
'''[[CABG]]:''' [[Coronary artery bypass grafting]];
'''CRT:''' [[Cardiac resynchronization therapy]];
'''LV:''' [[Left ventricle]];
'''ERO:'''[[Effective regurgitation orifice area]] ;
'''PCI:'''[[ Percutaneous coronary intervention]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];
'''TAVI:''' [[ Transcatheter aortic valve implantation]]

 

===U===

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | | C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2 | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===I===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-

|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered when the results of surgical technique are expected to be durable 
❑ [[Surgery]] is recommended in low risk symptomatic [[patients]] 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with preserved [[LV function]] ([[LVESD]] <40 mm and [[LVEF]] >60%) and [[AF]] secondary to [[mitral regurgitation]] or [[pulmonary hypertension]] ([[SPAP]] at rest >50 [[mmHg]]) 
❑[[Surgical]] [[mitral valve]] repair is recommended in low-risk asymptomatic [[patients]] with [[LVEF]] > 60%, [[LVESD]] <40 mmd and significant [[LA]] dilatation ([[volume index]] ≥60 mL/m2 or [[diameter]] ≥55 mm) 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility 
|
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrial]];
'''LV:''' [[Left ventricle]];
'''LVESD:'''[[Left ventricular end systolic diameter]] ;
'''SPAP:'''[[Systolic pulmonary arterial pressure]];
'''LVEF:''' [[Left ventricular ejection fraction]];
'''TEER:''' [[ Transcatheter edge to edge repair]];


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===O===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in aortic stenosis'''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Symptomatic [[aortic stenosis]]:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is considered in [[symptomatic]] [[patients]] with severe, high-gradient [[aortic stenosis]] [[mean gradient]] ≥ 40 mmHg, peak velocity
≥ 4.0 m/s, and [[valve]] area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2) 
❑ntervention is considered in symptomatic [[patients]] with severe low-[[flow]] ([[SVi]] ≤35 mL/m2), low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with reduced [[ejection fraction]] (<50%), and evidence of [[flow]] (contractile) reserve 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in symptomatic severe [[AS]] with low-[[flow]], low-[[gradient]] (<40 mmHg) [[aortic stenosis]] with normal [[ejection fraction ]] 
❑ [[Intervention]] is recommended in symptomatic [[patients]] with low-flow, low-[[gradient]] severe [[aortic stenosis]] and reduced [[ejection fraction]] without flow (contractile) reserve, severe [[aortic stenosis]] proven by [[CCT]] [[calcium]] score 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class III, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is not recommended in [[patients]] with severe [[comorbidities]] when the [[intervention]] is unlikely to improve [[quality of life]] or prolong [[survival]] >1 year 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Asymptomatic severe aortic stenosis :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction]] ([[LVEF]] < 50%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]], symptomtomatic on [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Intervention]] should be considered in asymptomatic [[patients]] with severe [[aortic stenosis]] and [[systolic LV dysfunction ]] ([[LVEF]] <55%) without another cause 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Interventin]] is recommended in asymptomatic [[patients]] with severe [[aortic stenosis]] and a sustained fall in[[blood pressure]] (>20 mmHg) during [[exercise]] testing
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Intervention ]] is considered in asymptomatic [[patients ]]with LVEF >55% and a normal [[exercise]] test if the procedural risk is low and in the presence of one of the following:
* Very severe [[aortic stenosis]] (mean gradient ≥60 [[mmHg]] or [[Vmax]] > 5 m/s 
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year 
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes 
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Type of intervention:'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Aortic valve]] [[interventions]] should be performed in an experienced center 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[SAVR]] is recommended in [[younger]] [[patients]] who are low risk for [[surgery]] (<75 yearse and STS PROM/EuroSCORE II <4%), or in [[patients]] who are operable and unsuitable for [[transfemoral TAVI]] 
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TAVI]] is recommended in [[older]] [[patients]] (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for [[surgery]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Non-[[transfemoral]] [[TAVI]] may be considered in [[patients]] who are inoperable and unsuitable for transfemoral [[TAVI]].
❑[[Balloon aortic valvotomy]] may be considered as a bridge to [[SAVR]] or [[TAVI]] in [[hemodynamically]] unstable [[patients]] and (if feasible) in those with
severe [[aortic stenosis]] who require [[urgent]] high risk non-[[cardiac]] [[surgery]] 
|}
'''Abbreviations:'''
'''BNP:''' [[B-type natriuretic peptide]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''CCT:'''[[Cardiac computed tomography]];
'''SAVR:''' [[Surgical aortic valve replacement]];
'''STS-PROM:''' [[ Society of Thoracic Surgeons - predicted risk of mortality]];
'''SVi:''' [[Stroke volume index]];
'''TAVI:'''[[Transcatheter aortic valve implantation]] ;
'''Vmax:'''[[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===R===

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Higher [[surgical]] risk
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Younger [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Older [[age]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Previous [[cardiac]] [[surgery]] ([[CABG]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Endocarditis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Anatomical and procedural factors}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[TAVI]] feasible via [[transfemoral]] approach
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inaccessable Transfemoral approach or [[SAVR]] feasible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Sequelae of [[chest]] [[radiation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Porcelain [[aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | High likelihood of severe [[patient]]-[[prosthesis]] mismatch ([[AVA]] <0.65 cm2/m2 [[BSA]])

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[chest]] deformity or [[scoliosis]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unsuitable [[aortic]] annular dimensions for [[TAVI]] device

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisuspid aortic valve]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Unfavourable [[valve]] morphology for [[TAVI]] (high risk of [[coronary]] obstruction due to low [[coronary]] ostia or heavy [[leaflet]]/[[LVOT]] [[calcification]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Thrombus]] in [[aorta]] or [[left ventricle]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Concomitant cardiac conditions requiring interventio}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant multi-vessel [[CAD]] requiring [[surgical]] [[revascularization]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe primary [[mitral valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[tricuspid valve]] [[disease]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant dilatation/[[aneurysm]] of the [[aortic]] root and/or [[ascending aorta]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]

| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
|}
'''Abbreviations:'''
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVOT:''' [[Left ventricular outflow tract]] ;
'''SAVR:''' [[Surgical aortic valve replacement]];
'''TAVI:''' [[Transcatheter aortic valve implantation]];
'''BSA:''' [[Body surface area]];
'''CAD:''' [[Coronary artery disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Y===

{{Family tree/start}}
{{Family tree| | | | | B01 | | | |B01= Valvular [[AS]]
* Assessment of [[velocity]], [[gradient]]}}
{{Family tree| | |,|-|-|^|-|-|.| | }}
{{Family tree| | C01 | | | | C02 |C01=Low-[[gradient]] [[AS]]
*Vmax < 4 m/s
*ΔPm < 40 mmHg|C02= High-[[gradient]] [[AS]]
*Vmax ≥ 4 m/s,
*ΔPm ≥ 40 mmHg}}
{{Family tree| | |!| | | | | | |!| | | | | | | | | | |}}
{{Family tree| | C1 | | | | | C3 | | | | | | | |C3=High [[flow]] status |C1=[[AVA]] ≤ 1.0 cm2 | | |}}
{{Family tree| |,|^|-|-|.| | | |,|^|-|-|-|.| | | | | |}}
{{Family tree| |T | |L1 | |C4 | | | C5| | | | | | | |C4= Yes
*Assessment of normal [[flow]] [[condition]]|L1=NO
*Moderate [[AS]]|T=Yes
*Determination of [[flow]] [[status]]|C5=NO
* Severe [[AS]] |}}
{{Family tree|,|^|-|-|.| | | | | | | | | | | |}}
{{Family tree| Y | | K | | | | | |Y= Normal [[flow]]
*[[SV]]i > 35 mL/m2 |K=Low [[flow]]
*[[SVi]] ≤ 35 mL/m2}}
{{Family tree| |!| | |!| | | | | | | | | | | | | | | | |}}
{{Family tree| T1| | P1| | | | | | | | | | | | | |T1= Severe [[AS]] unlikely |P1=[[LVEF]] ≥ 50%}}
{{Family tree| | | |,|^|-|-|.| | | | | | | | | | | | |}}
{{Family tree| | |F1 | |F2 | | | | | | | | | | | | | | |F1=NO
* [[DSE]] [[flow]] reservec |F2=Yes
* [[CCT]] to assess [[AV]] [[calcification]] }}
{{Family tree| |,|^|-|-|.| | | | | | | | | | | | | | |}}
{{Family tree| R1 | |R2 | | | | | | | | | | | | |R1=NO, [[CCT]] to assess [[AV]] [[calcification]] |R2=Yes, [[AVA]] ≤ 1.0 cm2 |}}
{{Family tree| | | | |,|^|-|.| | | | | | | | | | | | |}}
{{Family tree| | | | X1| | X2| | | | | | | | | | | | |X1= Yes
* Severe [[AS]] |X2=NO
*Pseudo-severe [[AS]]}}
{{Family tree/end}}
'''Abbreviations:'''
'''AS:''' [[Aortic stenosis]];
'''AV:''' [[Aortic valve]];
'''AVA:''' [[Aortic valve area]];
'''LVEF:''' [[Left ventricular ejection fraction]] ;
'''CT:''' [[Computed tomography]];
'''△Pm:''' [[Mean pressure gradient]];
'''DSE:''' [[Dobutamine stress echocardiography]];
'''LV:''' [[Left ventricular]];
'''SVi:''' [[Stroke volume index]];
'''Vmax:''' [[Peak transvalvular velocity]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

*High flow is reversible in [[conditions]] such as [[anemia]], [[hyperthyroidism]] or[[ arterio-venous fistula]] and may also be present in [[patients]] with [[hypertrophic obstructive cardiomyopathy]].
* The definition of Normal flow by [[pulsed Doppler echocardiography]] is :
*: [[Cardiac index]] 4.1 L/min/m2 in [[men]] and [[women]]
*: [[SVi]] 54 mL/m2 in [[men]], 51 mL/m2 in [[women]]
*[[DSE]] flow reserve is defined as > 20% increase in [[stroke volume]] in response to low-dose [[dobutamine]].
*Pseudo-severe [[aortic stenosis]] is defined as [[AVA]] >1.0 cm2 with increased [[flow]].
*[[ CT]] measurement of [[aortic valve ]] [[calcification]] (Agatston units) for definition of high likely [[severe]] [[AS]]:
*:men >3000, [[ women]]>1600
*:Likely: [[men]] >2000, [[women]] >1200
*:Unlikely: [[men]] <1600, [[women]] <800

===E===

{{Family tree/start}}
{{Family tree | | | | B01 | | | |B01= Management of [[aortic regurgitation]]}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Significant enlargement of [[ascending aorta]]| C02= Severe [[aortic regurgitation]]}}
{{Family tree | |!| | | | | |!| | | | | | | | | | | |}}
{{Family tree | C | | | | D | | | | | | | | | | | | |C=[[Surgery]]|D=[[Symptoms]]}}
{{Family tree | | | | | |,|-|^|-|-|.| | | | | | | | |}}
{{Family tree | | | | | S| | | E | | | | | | | | |S=Yes
* [[Surgery]]|E=NO
* [[LVEF]]≤ 50% or
* [[LVESD]] > 50 mm (or > 25 mm/m2 [[BSA]]) }}
{{Family tree | | | | | | | | | |!| | | | | | | | | |}}
{{Family tree | | | | | | | | | G| | | | | | | | | G=Yes
* [[Surgery]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm '''
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function 
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LVESD]] > 50 mm or [[LVESD]] > 25 mm/m2 [[BSA]] (in [[patients]] with small body size) or resting [[LVEF]] ≤ 50%
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIb, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Surgery]] may be considered in asymptomatic [[patients]] with [[LVESD]] >20 mm/m2 [[BSA]] (especially in [[patients]] with small [[body]] size) or resting [[LVEF]] ≤ 55%, in low risk [[condition]] 
❑Aortic valve repair may be considered in
selected patients at experienced centres when
durable results are expected
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Surgery is recommended in symptomatic and asymptomatic [[patients]] with severe [[aortic regurgitation]] undergoing [[CABG]] or surgery of the ascending [[aorta]] or of another [[valve]]
|-
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | ''' Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]]-sparing [[aortic]] root replacement is recommended in [[young]] [[patients]] with [[aortic]] root dilation 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending [[aortic]] surgery is recommended in [[patients]] with [[Marfan]] syndrome and [[ascending aortic]] diameter ≥ 50 mm 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Ascending aortic [[surgery]] is recommended with ascending [[aorta]] size of:
* >_55 mm in all [[patients]]
* >_45 mm in [[Marfan]] syndrome and additional risk factors or in the presence of [[TGFBR1]] or [[TGFBR2]] mutation (including [[Loeys Dietz syndrome]]) 
Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year 
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]] 
❑ In the presence of primarily indication for the [[surgery]] of [[aortic valve]], replacement of the [[aortic root]] or tubular ascending [[aorta]] should be considered
when ≥ 45 mm 
|}
'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===W===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[AF]] [[patients]] and [[mitral regurgitation]], [[aortic regurgitation]], and [[aortic stenosis]], [[NOACs]] are preferred to [[VKAs]] for prevention of [[stroke]] 
.
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' NOAC ([[ ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOACs ]] is not recommended in [[patients]] with [[AF]] and moderate to severe [[mitral stenosis]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' AF ablation:([[ESC guidelines classification scheme|Class IIa, Level of Evidence A]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Concomitant [[AF]] ablation should be considered in [[patients]] undergoing [[valve]] surgery with respect to risk factors of recurrence ([[LA]] dilatation, years in [[AF]], [[age]], [[renal dysfunction]], and other [[cardiovascular]] risk factors
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[LAA occlusion]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[LAA]] occlusion should be considered to reduce the [[thromboembolic]] risk in [[patients]] with [[AF]] and a [[CHA2DS2VASc]] score ≥ 2 undergoing [[valve]] [[surgery]] 
|}
'''Abbreviations:'''
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''LAA:''' [[Left atrial appendage]];
'''NOAC:'''[[Non vitamin-K antagonist oral anticoagulant]] ;
''' OAC:'''[[ Oral anticoagulation]];
'''VKA:''' [[Vitamin-K antagonist]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===Q===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]] 
* Suspected [[myocardial ischemia]] 
* [[Left ventricular]] [[systolic dysfunction]] 
* In men >40 years of age and [[postmenopausal]] [[women]] 
* One or more [[cardiovascular]] [[risk factors]] 
* Evaluation of severe [[mitral regurgitation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]] ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments 
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]


 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}

===D===

==[[Endocarditis]] [[prophylaxis]]==
*[[Antibiotic]] prophylaxis should be considered for high-risk procedures in [[patients]] with prosthetic [[valves]] including:
*: [[Transcatheter valves]]
*: Valve repaired using [[prosthetic]] material
*: History of previous episode(s) of [[infective endocarditis]]
* Specific attention to [[dental]] and [[cutaneous]] hygiene and strict [[aseptic]] measures during any invasive procedure are recommended.
* [[Antibiotic prophylaxis]] should be considered in [[dental]] procedures including the manipulation of the [[gingival]] or [[periapical]] region of the [[teeth]] or manipulation of the [[oral]] mucosa
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulant therapy in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

== Prophylaxis for [[rheumatic fever]]==
* [[Antibiotic]] therapy of group A [[Streptococcus]] infection [[throat]] is necessary in [[primary prevention]] of [[rheumatic fever]].
* Screening with [[echocardiographic]] in combination with secondary prevention by [[antibiotic]] prophylaxis in [[children]] with evidence of latent [[rheumatic heart disease]] are considered to reduce the [[prevalence]] of [[disease]] in [[endemic]] regions.
* Recommendation for secondary long-term [[prophylaxis]] against [[rheumatic fever]] in [[patients]] with established [[rheumatic heart disease]] is [[benzathine benzyl penicillin]] 1.2 MUI every 3 to 4 weeks over 10 years.
* Lifelong [[prophylaxis]] is recommended in high-risk [[patients]] based upon the severity of [[VHD]] and exposure to group A [[Streptococcus]].

===F===

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for anticoagulation for atrial fibrillation in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''NOAC ([[ AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Except those with rheumatic [[mitral stenosis]], [[NOAC]] is recommended in [[patients]] with [[AF]] and [[VHD]] , or who received a [[bioprothesis]] valve > 3 months ago on the basis of [[CHA2DS2-VASc]] score
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''VKA ([[ AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Long term [[VKA]] oral [[anticoagulation]] is recommended in [[patients]] with [[AF]] and [[rheumatic MS]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' VKA:([[AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Anticoagulation]] with [[VKA]] is reasonable in [[patients]] with new onset [[AF]] ≤ 3 months after [[surgical]] or transcatheter [[bioprothetic]] [[valve replacement]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''NOAC : ([[AHA guidelines classification scheme|Class III: Harm, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[NOAC]] is not recommended in [[patients]] with [[mechanical]] [[valve]] with or without [[AF]], and [[VKA]] should be continued for prevention of [[valve]] [[thrombosis]] formation 

|}
'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]]

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
|-
|}

===F===

==Median Operative[[ Mortality Rates]] for Specific Surgical Procedures==
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.2
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 4
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]] + [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve replacement]] + [[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 9
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 1
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mitral valve repair]] +[[CABG]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 5
|-
|}
{{clear}}

{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | |A01=Management of [[HFrEF]]}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | B01 | | | | | |B01=(Class I)
*[[ACE-I]]/[[ARNI]]
*[[Beta-blocker]]
*[[Mineralocorticoid receptor antagonist]]
*[[Dapagliflozin]]/[[Empagliflozin]]
*[[Loop diuretic]] for [[fluid retention]]
}}
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=[[LVEF]] ≤35% and
[[QRS]] <130 ms|C02=[[LVEF]] >35% or device
therapy not indicated
or inappropriate|C03=[[Sinus rhythm]] and [[LVEF]] ≤35% and [[QRS]] ≥130 ms}}
{{familytree | | |!| | | | | | |!| | | | | | |!| |}}
{{familytree | | |A |-|-|-|-| B |-|-|-|-| C | | | |A=[[ICD]] implantation
*[[Ischemic]] (class I)
* [[Non-ischemic]] (class IIa)|B=If [[symptoms]] persist, consider therapies (class II)|C= [[CRT]]-D/-P
*[[QRS]] ≥150 ms (Class I)
*[[QRS]] 130-149 ms (Class IIa)
}}
{{familytree/end}}

{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | }}
{{Family tree | A6 | | | | | A7| | |A6= [[Loop diuretics]] (Class I) and/or [[vasodilators]] (Class IIb)|A7=[[Signs]] of [[hypoperfusion]] }}
{{Family tree | |:| | | | |,|-|^|-|.| | | |}}
{{Family tree | |:| | | | | A8| |A9 | | |A8=Yes|A9=NO}}
{{Family tree | |:| | | | |!| | | |!| | | }}
{{Family tree | |:| | | | |A10| |A11| |A10=[[Loop diuretics]] (Class I) and [[inotropes]]/[[vasopressors]](Class IIb)|A11=[[Loop diuretics]] (Class I)}}
{{Family tree | |`|-|-|-|-|v|-|-|-|'| | | | }}
{{Family tree | | | | | | | A12 | | | A12=[[Congestion]] relief}}
{{Family tree | | | | | |,|-|^|-|.| | |}}
{{Family tree | | | | | |A13| |A14| | |A13=Yes|A14=NO}}
{{Family tree | | | | | |!| | | |!| |}}
{{Family tree | | | | | |A15| |A16| | A15= Optimized [[medical therapy]]| A16= [[Renal replacement therapy]]
*[[ Mechanical circulatory support]]
* [[Palliative therapy]]}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline
|-
|}

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with [[SpO2]]<90% or [[PaO2]] <60 mmHg 
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented with [[signs]], [[symptoms]] of [[fluid]] overload 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]] 

|}
'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]] ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];

 

{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}

== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==

{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f | | E0

Ventricular tachycardia medical therapy

2022-09-16T05:08:39Z

Sara Zand: /* Notes */

__NOTOC__
{{Ventricular tachycardia}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}, [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]
==Overview==
The mainstay of medical therapy in hemodynamic stable [[VT]] is suppression of [[tachyarrhythmia]] with [[antiarrhythmic]] [[medications]] such as [[amiodarone]], [[sotalol]], [[lidocaine]], [[betablocker]] alongside with correction of [[hypokalemia]], [[hypomagnesemia]] and [[hypocalcemia]]. In addition, treating the underlying causes of [[VT]] including
[[ischemic heart disease]] or [[decompensated heart failure]]
are warranted.

==Medical Therapy==
Common [[medications]] for treatment of [[VT]] include:<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref>
==[[Antiarrhythmic]] [[medications]]==
<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>

===[[Sodium channel blocker]]===
* In [[patients]] with [[ischemic heart disease]], chronic use of [[sodium channel blocker]] increased risk of [[mortality]].
* Some [[sodium channel blockers]] with benefit in special setting include the following:
:* [[Lidocaine]] (class1) for [[patients]] with refractory [[VT]], [[cardiac arrest]] (especially [[witnessed]]) <ref name="KudenchukBrown2016">{{cite journal|last1=Kudenchuk|first1=Peter J.|last2=Brown|first2=Siobhan P.|last3=Daya|first3=Mohamud|last4=Rea|first4=Thomas|last5=Nichol|first5=Graham|last6=Morrison|first6=Laurie J.|last7=Leroux|first7=Brian|last8=Vaillancourt|first8=Christian|last9=Wittwer|first9=Lynn|last10=Callaway|first10=Clifton W.|last11=Christenson|first11=James|last12=Egan|first12=Debra|last13=Ornato|first13=Joseph P.|last14=Weisfeldt|first14=Myron L.|last15=Stiell|first15=Ian G.|last16=Idris|first16=Ahamed H.|last17=Aufderheide|first17=Tom P.|last18=Dunford|first18=James V.|last19=Colella|first19=M. Riccardo|last20=Vilke|first20=Gary M.|last21=Brienza|first21=Ashley M.|last22=Desvigne-Nickens|first22=Patrice|last23=Gray|first23=Pamela C.|last24=Gray|first24=Randal|last25=Seals|first25=Norman|last26=Straight|first26=Ron|last27=Dorian|first27=Paul|title=Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest|journal=New England Journal of Medicine|volume=374|issue=18|year=2016|pages=1711–1722|issn=0028-4793|doi=10.1056/NEJMoa1514204}}</ref>
:*Oral [[mexiletine]] for [[congenital long QT syndrome]]<ref name="MazzantiMaragna2016">{{cite journal|last1=Mazzanti|first1=Andrea|last2=Maragna|first2=Riccardo|last3=Faragli|first3=Alessandro|last4=Monteforte|first4=Nicola|last5=Bloise|first5=Raffaella|last6=Memmi|first6=Mirella|last7=Novelli|first7=Valeria|last8=Baiardi|first8=Paola|last9=Bagnardi|first9=Vincenzo|last10=Etheridge|first10=Susan P.|last11=Napolitano|first11=Carlo|last12=Priori|first12=Silvia G.|title=Gene-Specific Therapy With Mexiletine Reduces Arrhythmic Events in Patients With Long QT Syndrome Type 3|journal=Journal of the American College of Cardiology|volume=67|issue=9|year=2016|pages=1053–1058|issn=07351097|doi=10.1016/j.jacc.2015.12.033}}</ref>
:*[[Quinidine]] for [[patients]] with [[Brugada]] syndrome
:* [[Flecainide]] for [[patients]] with [[catecholaminergic polymorphic ventricular tachycardia]]<ref name="WatanabeChopra2009">{{cite journal|last1=Watanabe|first1=Hiroshi|last2=Chopra|first2=Nagesh|last3=Laver|first3=Derek|last4=Hwang|first4=Hyun Seok|last5=Davies|first5=Sean S|last6=Roach|first6=Daniel E|last7=Duff|first7=Henry J|last8=Roden|first8=Dan M|last9=Wilde|first9=Arthur A M|last10=Knollmann|first10=Björn C|title=Flecainide prevents catecholaminergic polymorphic ventricular tachycardia in mice and humans|journal=Nature Medicine|volume=15|issue=4|year=2009|pages=380–383|issn=1078-8956|doi=10.1038/nm.1942}}</ref>
::* Theses [[medications]] are useful in [[ICD]] [[patients]] with [[drug]] and ablation refractory [[VT]].

===[[Ranolazine]]===
:* A new [[antiangina]] drug approved by [[FDA]] with [[antiarrhythmic]] efficacy.
:*Mechanism of action is late [[sodium]] channel current blockade , blockade of the phase 3 [[repolarizing]] [[potassium]] current.
:* Reducion [[ICD]] shocks in drug resistant [[VT]], [[VF]]<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref>

:* Reducion [[VT]] in the first days after [[NSTEMI]] according to [[MERLIN TIMI-36]].<ref name="SciricaBraunwald2010">{{cite journal|last1=Scirica|first1=Benjamin M.|last2=Braunwald|first2=Eugene|last3=Belardinelli|first3=Luiz|last4=Hedgepeth|first4=Chester M.|last5=Spinar|first5=Jindrich|last6=Wang|first6=Whedy|last7=Qin|first7=Jie|last8=Karwatowska-Prokopczuk|first8=Ewa|last9=Verheugt|first9=Freek W.A.|last10=Morrow|first10=David A.|title=Relationship Between Nonsustained Ventricular Tachycardia After Non–ST-Elevation Acute Coronary Syndrome and Sudden Cardiac Death|journal=Circulation|volume=122|issue=5|year=2010|pages=455–462|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.110.937136}}</ref>

:* NO efficacy in reduction the fist [[VT]], [[VF]] in high risk [[patients]], but significant reduction of recurrent [[VT]], [[VF]] requiring [[ICD]] implantation.<ref name="ZarebaDaubert2018">{{cite journal|last1=Zareba|first1=Wojciech|last2=Daubert|first2=James P.|last3=Beck|first3=Christopher A.|last4=Huang|first4=David T.|last5=Alexis|first5=Jeffrey D.|last6=Brown|first6=Mary W.|last7=Pyykkonen|first7=Kathryn|last8=McNitt|first8=Scott|last9=Oakes|first9=David|last10=Feng|first10=Changyong|last11=Aktas|first11=Mehmet K.|last12=Ayala-Parades|first12=Felix|last13=Baranchuk|first13=Adrian|last14=Dubuc|first14=Marc|last15=Haigney|first15=Mark|last16=Mazur|first16=Alexander|last17=McPherson|first17=Craig A.|last18=Mitchell|first18=L. 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===[[Beta blocker]]===
:* First line therapy for the most of [[ventricular arrhythmia]] such as [[PVC]], [[VT]] because of safety and efficacy<ref name="ReiterReiffel1998">{{cite journal|last1=Reiter|first1=Michael J.|last2=Reiffel|first2=James A.|title=Importance of beta blockade in the therapy of serious ventricular arrhythmias|journal=The American Journal of Cardiology|volume=82|issue=4|year=1998|pages=9I–19I|issn=00029149|doi=10.1016/S0002-9149(98)00468-8}}</ref>

:* Supression of [[ventricular arrhythmia]] in [[structurally normal heart]].
:* Reducing all-cause mortality and [[SCD]] in [[patients]] with [[heart failure]] with reduced [[EF]]<ref name="pmid10376614">{{cite journal |vauthors= |title=Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) |journal=Lancet |volume=353 |issue=9169 |pages=2001–7 |date=June 1999 |pmid=10376614 |doi= |url=}}</ref>
:* Reducing [[mortality]] after [[MI]]
:* Increased [[mortality]] and risk of [[cardiogenic shock]] after [[MI]] in the presence of >70 years of age, symptoms <12 hours [[ST-elevation MI]] [[patients]], [[systolic blood pressure ]]<120 mm Hg, [[heart rate ]]>110 beat/min <ref name="KontosDiercks2011">{{cite journal|last1=Kontos|first1=Michael C.|last2=Diercks|first2=Debra B.|last3=Ho|first3=P. Michael|last4=Wang|first4=Tracy Y.|last5=Chen|first5=Anita Y.|last6=Roe|first6=Matthew T.|title=Treatment and outcomes in patients with myocardial infarction treated with acute β-blocker therapy: Results from the American College of Cardiology’s NCDR®|journal=American Heart Journal|volume=161|issue=5|year=2011|pages=864–870|issn=00028703|doi=10.1016/j.ahj.2011.01.006}}</ref>
:*Increased [[antiarrhythmic]] effect of membrane stabilizing drug in [[malignant]] [[VT]].<ref name="HirsowitzPodrid1986">{{cite journal|last1=Hirsowitz|first1=Geoffrey|last2=Podrid|first2=Philip J.|last3=Lampert|first3=Steven|last4=Stein|first4=Joseph|last5=Lown|first5=Bernard|title=The role of beta blocking agents as adjunct therapy to membrane stabilizing drugs in malignant ventricular arrhythmia|journal=American Heart Journal|volume=111|issue=5|year=1986|pages=852–860|issn=00028703|doi=10.1016/0002-8703(86)90633-2}}</ref>
:*[[Nadolol]], [[propranolol]]: first-line therapy for some [[cardiac]] channelopathies such as [[long QT syndrome]], [[catecholaminergic polymorphic ventricular tachycardia]]

===[[Amiodarone]], [[sotalol]]===
* [[ Amiodarone]] is a multichannel blocker by blockade of [[beta receptors]], [[sodium]], [[calcium]], [[potassium]] currents
* NO survival benefit from [[amiodarone]] compared with placebo in [[patients]] with [[LV dysfunction]] due to [[prior MI]] and [[non ischemic cardiomyopathy]] according to [[SCD-HeFT]]<ref name="BardyLee2005">{{cite journal|last1=Bardy|first1=Gust H.|last2=Lee|first2=Kerry L.|last3=Mark|first3=Daniel B.|last4=Poole|first4=Jeanne E.|last5=Packer|first5=Douglas L.|last6=Boineau|first6=Robin|last7=Domanski|first7=Michael|last8=Troutman|first8=Charles|last9=Anderson|first9=Jill|last10=Johnson|first10=George|last11=McNulty|first11=Steven E.|last12=Clapp-Channing|first12=Nancy|last13=Davidson-Ray|first13=Linda D.|last14=Fraulo|first14=Elizabeth S.|last15=Fishbein|first15=Daniel P.|last16=Luceri|first16=Richard M.|last17=Ip|first17=John H.|title=Amiodarone or an Implantable Cardioverter–Defibrillator for Congestive Heart Failure|journal=New England Journal of Medicine|volume=352|issue=3|year=2005|pages=225–237|issn=0028-4793|doi=10.1056/NEJMoa043399}}</ref>
* Use of [[amiodarone]] after [[MI]] in patients with NYHA 3 [[symptoms]] was associated with increased risk of [[mortality]].<ref name="ThomasAl-Khatib2008">{{cite journal|last1=Thomas|first1=Kevin L.|last2=Al-Khatib|first2=Sana M.|last3=Lokhnygina|first3=Yuliya|last4=Solomon|first4=Scott D.|last5=Kober|first5=Lars|last6=McMurray|first6=John J.V.|last7=Califf|first7=Robert M.|last8=Velazquez|first8=Eric J.|title=Amiodarone use after acute myocardial infarction complicated by heart failure and/or left ventricular dysfunction may be associated with excess mortality|journal=American Heart Journal|volume=155|issue=1|year=2008|pages=87–93|issn=00028703|doi=10.1016/j.ahj.2007.09.010}}</ref>
* In [[patients]] with [[nonischemic cardiomyopathy]] ([[LVEF]]<40%), use of [[amiodarone]] reduced the risk of [[SCD]] (with low quality of support of article), but there was NO benefit of using [[amiodarone]] for [[secondary prevention]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>

* Infused [[amiodarone]] during [[cardiopulmonary resuscitation]] prevents recurrent [[VT]], [[VF]].<ref name="KudenchukCobb1999">{{cite journal|last1=Kudenchuk|first1=Peter J.|last2=Cobb|first2=Leonard A.|last3=Copass|first3=Michael K.|last4=Cummins|first4=Richard O.|last5=Doherty|first5=Alidene M.|last6=Fahrenbruch|first6=Carol E.|last7=Hallstrom|first7=Alfred P.|last8=Murray|first8=William A.|last9=Olsufka|first9=Michele|last10=Walsh|first10=Thomas|title=Amiodarone for Resuscitation after Out-of-Hospital Cardiac Arrest Due to Ventricular Fibrillation|journal=New England Journal of Medicine|volume=341|issue=12|year=1999|pages=871–878|issn=0028-4793|doi=10.1056/NEJM199909163411203}}</ref>
* [[Amiodarone]] decreased risk of [[SCD]] and all-cause [[mortality ]] compared with [[betablocker]] or [[sotalol]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>
*Chronic use of [[amiodarone]] has adverse effect on [[lung]], [[liver]], [[thyroid]], [[skin]], and [[nervous system]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>
* [[ECG]], [[liver function tests]], [[thyroid function tests]], [[chest x-ray]], and [[pulmonary function tests]] (including diffusing capacity of the [[lungs]] for [[carbon monoxide]]) is needed before administration of [[amiodarone]]. In case of [[pulmonary]] toxicity, [[chest CT scan]] should be done.<ref name="EpsteinOlshansky2016">{{cite journal|last1=Epstein|first1=Andrew E.|last2=Olshansky|first2=Brian|last3=Naccarelli|first3=Gerald V.|last4=Kennedy|first4=John I.|last5=Murphy|first5=Elizabeth J.|last6=Goldschlager|first6=Nora|title=Practical Management Guide for Clinicians Who Treat Patients with Amiodarone|journal=The American Journal of Medicine|volume=129|issue=5|year=2016|pages=468–475|issn=00029343|doi=10.1016/j.amjmed.2015.08.039}}</ref>
* Although [[sotalol]] suppressed [[ventricular arrhythmia]], it was associated with increased risk of [[mortality]] in [[heart failure]] [[patients]].<ref name="pmid7747682">{{cite journal |vauthors=Waldo AL, Camm AJ, deRuyter H, Freidman PL, MacNeil DJ, Pitt B, Pratt CM, Rodda BE, Schwartz PJ |title=Survival with oral d-sotalol in patients with left ventricular dysfunction after myocardial infarction: rationale, design, and methods (the SWORD trial) |journal=Am J Cardiol |volume=75 |issue=15 |pages=1023–7 |date=May 1995 |pmid=7747682 |doi=10.1016/s0002-9149(99)80717-6 |url=}}</ref>
* [[Sotalol]] may decrease [[defibrillation threshold]] and should be avoided in patients with [[LVEF]]< 20% due to decompensation of [[heart failure]].<ref name="Page2000">{{cite journal|last1=Page|first1=Richard L|title=Effects of antiarrhythmic medication on implantable cardioverter-defibrillator function|journal=The American Journal of Cardiology|volume=85|issue=12|year=2000|pages=1481–1485|issn=00029149|doi=10.1016/S0002-9149(00)00799-2}}</ref>

===[[ Calcium channel blocker]]===
* [[Non-dihydropyridines calcium channel blockers]] have no role in the treatment of most [[ventricular arrhythmia]]s.
* In [[patients]] with prior [[MI]], administration of intravenous [[verapamil]] for sustained [[VT]] has been associated with [[hemodynamic collapse ]].<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>
* [[Verapamil]] and [[diltiazem]] can be used for suppression of some [[VT]] originated outflow tract.<ref name="GillWard1992">{{cite journal|last1=Gill|first1=Jaswinder S.|last2=Ward|first2=David E.|last3=Camm|first3=A. John|title=Comparison of Verapamil and Diltiazem in the Suppression of Idiopathic Ventricular Tachycardia|journal=Pacing and Clinical Electrophysiology|volume=15|issue=11|year=1992|pages=2122–2126|issn=0147-8389|doi=10.1111/j.1540-8159.1992.tb03033.x}}</ref>
* Oral and intravenous [[verapamil ]] is effective for the treatment of idiopathic interfascicular reentrant left [[VT]] in [[patients]] with normal structurally [[heart]].<ref name="BadhwarScheinman2007">{{cite journal|last1=Badhwar|first1=Nitish|last2=Scheinman|first2=Melvin M.|title=Idiopathic Ventricular Tachycardia: Diagnosis and Management|journal=Current Problems in Cardiology|volume=32|issue=1|year=2007|pages=7–43|issn=01462806|doi=10.1016/j.cpcardiol.2006.10.002}}</ref>
*[[Non-dihydropyridines]] [[Calcium channel blockers]] should be avoided for converting [[VT]] in [[heart failure]] reduced [[EF]].

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Arrhythmiac medication, class, dose}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF| Indication}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF| Receptor target}}
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF| Electrophysiologic effect}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Pharmacological characteristics}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Common advers effects}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Acebutolol]]
PO 200–1200 mg daily, up to 600 mg bid
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | B1, mild internistic [[sympathetic]] activity
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowing [[sinus rate]], increasing [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[haft life]] in [[renal]] impairment, metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[Dizziness]], [[fatigue]], [[anxiety]], [[impotence]], [[hyperesthesia]],[[hypoesthesia]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Amiodarone ]] (III)
IV:[[VF]]/[[pulseless VT]] arrest: 300 mg bolus, stable [[VT]]: 150-mg bolus then 1 mg/min x 6 h, then 0.5 mg/min x 18 h
PO: 400 mg q 8 to 12 h for 1–2 wk, then 300–400 mg daily; reduce dose to 200 mg daily if possible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[INa]], [[ICa]], [[IKr]], [[IK1]], [[IKs]], [[Ito]], [[Beta receptor]], [[Alpha receptor]], [[nuclear T3]]
recepto
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QRS]] prolongation, [[QTc]] prolongation, increased [[AV ]] nodal refractoriness ,increased [[defibrilation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metabolism]]: [[hepatic]], half life: 26-107 days
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypotension]], [[bradycardia]], [[AV]] block, [[TdP]], slowing [[VT]] below programmed [[ICD]] detection rate, increased [[defibrillation threshold]], [[corneal microdeposits]], [[thyroid]] abnormalities, [[ataxia]], [[nausea]], [[emesis]], [[constipation]], [[photosensitivity]], [[skin]] discoloration, [[ataxia]], [[dizziness]], [[peripheral neuropathy]], [[tremor]], [[hepatitis]], [[cirrhosis]], [[pulmonary fibrosis]], [[pneumonitis]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Atenolol]] (II)
PO: 25–100 mg qd or bid
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[ARVC]], [[LQTS]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Beta 1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate ]],
increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[heart failure]], [[AV]] block, [[dizziness]], [[fatigue]], [[depression]], [[impotence]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisoprolol]] (II)
PO: 2.5–10 mg once daily
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Beta 1 receptor]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV ]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Chest pain]], [[bradycardia]], [[AV]] block, [[Fatigue]], [[insomnia]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Carvedilol]] (II)
PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1]], [[Beta 2]], [[Alpha]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], [[syncope]], [[Hyperglycemia]], [[dizziness]], [[fatigue]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Carvedilol]] (II)
PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1]], [[Beta 2]], [[Alpha]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], [[syncope]], [[Hyperglycemia]], [[dizziness]], [[fatigue]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Diltiazem]] (IV)
IV: 5–10 mg,qd: 15–30 min, Extended release: PO: 120–360 mg/da, PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[RVOT]] [[VT]], ideopathic left [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[ICa-L]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], slowed [[AV]] node conduction, [[PR]] prolongation
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], exacerbation of [[HF]] reduced [[EF]], [[Headache]], [[rash]], [[constipation]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Esmolol]] (II)
IV: 0.5 mg/kg bolus, 0.05 mg/kg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] node refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[RBC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[HF]], [[dizziness]], [[neusea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Flecainide]] (IC) PO: 50–200 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]] (in the absence of [[structural heart disease]]), [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]], [[IKur]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[PR]] interval, prolonged [[QRS]] duration, increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[RBC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Sinus node dysfunction]], [[AV]] block, [[drug]]-induced [[Brugada]] syndrome, [[monomorphic VT]] in patients with a [[myocardial]] scar, [[exacerbation]] of [[HFrEF]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Lidocaine]] (IB)
IV: 1 mg/kg bolus, 1–3 mg/min, 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg bolus every 5–10 min (max cumulative dose 3 mg/kg), maintenance infusion: 1–4 mg/min or starting 0.5 mg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slightly shortening of [[QTc]] interval
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]], prolonged half life in [[HF]], [[liver]] disease, [[shock]], severe [[renal]] disease
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hemodynamic collapse]], [[AV]] block, [[sinus arrest]], [[delirium]], [[psychosis]], [[seizure]], [[nausea]], [[tinnitus]], [[dyspnea]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metoprolol]] (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: None, Excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[dizziness]], [[fatigue]], [[diarrhea]], [[depression]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metoprolol]] (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: None, Excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[dizziness]], [[fatigue]], [[diarrhea]], [[depression]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mexiletine]] (IB), PO: 150–300 mg q 8 h or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[VF]], [[Long QT]]3
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slightly shortening of [[QTc]] interval
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[HF]], [[AV]] block, [[lightheaded]], [[tremor]], [[ataxia]], [[paresthesias]], [[nausea]], [[blood dyscrasias]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Nadolol]] (II)
PO: 40–320 mg daily
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[LQTS]], [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]], excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[edema]], [[dizziness]], [[cold extremities]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procainamide]] (IA), IV: loading dose 10–17 mg/kg at 20–50 mg/min, maintenance dose: 1–4 mg/min, PO (SR preparation): 500–1250 mg q 6 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[LQTS]], [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]], excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[edema]], [[dizziness]], [[cold extremities]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Propafenone]] (IC), PO: Immediate release 150–300 mg q 8 h, Extended release 225–425 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]] (in the absence of [[structural heart disease]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]], [[IKur]], [[ Beta receptor]], [[Alpha recept]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[PR]] interval, prolonged [[QRS]] duration, increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[HF]], [[AV]] block, drug-induced [[Brugada ]] syndrome, [[ dizziness]], [[fatigue]], [[nausea]], [[diarrhea]], [[xerostomia]], [[tremor]], [[blurred vision]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Propranolol]] (II), IV: 1–3 mg q 5 min to a total of 5 mg, PO: Immediate release 10–40 mg q 6 h; Extended release 60–160 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[Long QT]] syndrome
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1 ]], B2 , INa
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[sleep disorder]], [[dizziness]], [[nightmares]], [[hyperglycemia]], [[diarrhea]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Quinidine]] (IA), PO: sulfate salt 200–600 mg q 6 h to q 12 h, gluconate salt 324–648 mg q 8 h to q 12 h, IV: loading dose: 800 mg in 50 mL infused at 50 mg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[short QT syndrome]], [[brugada]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[Ito]], [[IKr]], M, Alpha receptor
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[QRS prolongation]], [[QTc prolongation]], increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Syncope]], [[ torsades de pointes]], [[AV]] block, [[dizziness]], [[diarrhea]], [[nausea]], [[esophagitis]], [[emesis]], [[tinnitus]], [[blurred vision]], [[rash]], [[weakness]], [[tremor]], [[blood dyscrasias]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ranolazine]] (not classified), PO: 500–1000 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QTc prolongation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[headache]], [[dizziness]], [[syncope]], [[nausea]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Sotalol]] (III), IV: 75 mg q 12 h, PO: 80–120 mg q 12 h, may increase dose every 3 d; max 320 mg/d
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]] [[IKr]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QTc prolongation]], increased [[AV]] nodal refractoriness, decreased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[syncope]], [[TdP]], [[fatigue]], [[dizziness]], [[weakness]], [[dyspnea]], [[bronchitis]], [[depression]], [[nausea]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Verapamil]], IV: 2.5–5 mg q 15–30 min, sustained release PO: 240–480 mg/d
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[RVOT]] [[VT]], [[verapamil]]-sensitive idiopathic [[Left VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[ICa-L]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]],[[PR]] prolongation, slowed [[AV]] nodal conduction
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Hypotension]], [[edema]], [[HF]], [[AV]] block, [[bradycardia]], exacerbation of [[HF]] reduced [[EF]], [[headache]], [[rash]], [[gingival hyperplasia]], [[constipation]], [[dyspepsia]]
|}
{{clear}}

==[[Electrolytes]]==
* Correction of [[hypokalemia]] and [[hypomagnesemia]] is helpful for preventing of [[ventricular arrhythmia]] in the setting of [[myocardial infarction]] or [[ diuretic]] therapy in [[heart failure]] [[patients]].<ref name="CooperDries1999">{{cite journal|last1=Cooper|first1=Howard A.|last2=Dries|first2=Daniel L.|last3=Davis|first3=C. E.|last4=Shen|first4=Yuan Li|last5=Domanski|first5=Michael J.|title=Diuretics and Risk of Arrhythmic Death in Patients With Left Ventricular Dysfunction|journal=Circulation|volume=100|issue=12|year=1999|pages=1311–1315|issn=0009-7322|doi=10.1161/01.CIR.100.12.1311}}</ref>
* [[Diuretic therapy]] in [[heart failure]] [[patients]] may lead to [[hypokalemia]] or [[hypomagnesemia]].<ref name="CooperDries1999">{{cite journal|last1=Cooper|first1=Howard A.|last2=Dries|first2=Daniel L.|last3=Davis|first3=C. E.|last4=Shen|first4=Yuan Li|last5=Domanski|first5=Michael J.|title=Diuretics and Risk of Arrhythmic Death in Patients With Left Ventricular Dysfunction|journal=Circulation|volume=100|issue=12|year=1999|pages=1311–1315|issn=0009-7322|doi=10.1161/01.CIR.100.12.1311}}</ref>

* [[Hypokalemia]] and [[hypomagnesemia]] may cause [[ventricular arrhythmia]] during acute [[myocardial infarction]] .
* [[Hypokalemia]] and [[hypomagnesemia]] may increase the risk of [[torsades de pointes]] in patients with use of some [[medications]] with [[QTc prolongation ]] effect or [[long QT syndrome]].<ref name="YanAntzelevitch1998">{{cite journal|last1=Yan|first1=Gan-Xin|last2=Antzelevitch|first2=Charles|title=Cellular Basis for the Normal T Wave and the Electrocardiographic Manifestations of the Long-QT Syndrome|journal=Circulation|volume=98|issue=18|year=1998|pages=1928–1936|issn=0009-7322|doi=10.1161/01.CIR.98.18.1928}}</ref>
* Administration of intravenous [[magnesium]] in the setting of [[torsades de pointes]] as the first line therapy is recommended.<ref name="TzivoniBanai1988">{{cite journal|last1=Tzivoni|first1=D|last2=Banai|first2=S|last3=Schuger|first3=C|last4=Benhorin|first4=J|last5=Keren|first5=A|last6=Gottlieb|first6=S|last7=Stern|first7=S|title=Treatment of torsade de pointes with magnesium sulfate.|journal=Circulation|volume=77|issue=2|year=1988|pages=392–397|issn=0009-7322|doi=10.1161/01.CIR.77.2.392}}</ref>

* [[Potassium]] level should be kept 4.5 mmol/L and 5 mmol/L to prevent [[ventricular arrhythmia]] or [[sudden cardiac death]].<ref name="CohnKowey2000">{{cite journal|last1=Cohn|first1=Jay N.|last2=Kowey|first2=Peter R.|last3=Whelton|first3=Paul K.|last4=Prisant|first4=L. Michael|title=New Guidelines for Potassium Replacement in Clinical Practice|journal=Archives of Internal Medicine|volume=160|issue=16|year=2000|pages=2429|issn=0003-9926|doi=10.1001/archinte.160.16.2429}}</ref>

* In [[patients]] with acute [[MI]] maintaining [[potassium]] level between 3.5 mmol/L and 4.5 mmol/L was associated with lower rate of [[death]] <ref name="GoyalSpertus2012">{{cite journal|last1=Goyal|first1=Abhinav|last2=Spertus|first2=John A.|last3=Gosch|first3=Kensey|last4=Venkitachalam|first4=Lakshmi|last5=Jones|first5=Philip G.|last6=Van den Berghe|first6=Greet|last7=Kosiborod|first7=Mikhail|title=Serum Potassium Levels and Mortality in Acute Myocardial Infarction|journal=JAMA|volume=307|issue=2|year=2012|pages=157|issn=0098-7484|doi=10.1001/jama.2011.1967}}</ref>
*Early administration of intravenous [[magnesium]] in [[patients]] with acute [[STEMI]] has not effect on short term [[mortality]].<ref name="Antman2002">{{cite journal|last1=Antman|first1=Elliott M|title=Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial|journal=The Lancet|volume=360|issue=9341|year=2002|pages=1189–1196|issn=01406736|doi=10.1016/S0140-6736(02)11278-5}}</ref>

==[[Fatty acids]], [[Lipids]]==
* The role of [[N-3 poly-unsaturated fatty acids]] and [[statin]] therapies for preventing of [[SCD]] has been proposed by stabilizing bilipid [[myocyte membrane]] for maintaining [[electrolyte]] gradients. <ref name="LeafKang2003">{{cite journal|last1=Leaf|first1=Alexander|last2=Kang|first2=Jing X.|last3=Xiao|first3=Yong-Fu|last4=Billman|first4=George E.|title=Clinical Prevention of Sudden Cardiac Death by n-3 Polyunsaturated Fatty Acids and Mechanism of Prevention of Arrhythmias by n-3 Fish Oils|journal=Circulation|volume=107|issue=21|year=2003|pages=2646–2652|issn=0009-7322|doi=10.1161/01.CIR.0000069566.78305.33}}</ref>
* Among [[patients]] with recent [[MI]] using [[fish oil]] 1 g/d reduced [[SCD]] and [[mortality]].<ref name="MarchioliBarzi2002">{{cite journal|last1=Marchioli|first1=Roberto|last2=Barzi|first2=Federica|last3=Bomba|first3=Elena|last4=Chieffo|first4=Carmine|last5=Di Gregorio|first5=Domenico|last6=Di Mascio|first6=Rocco|last7=Franzosi|first7=Maria Grazia|last8=Geraci|first8=Enrico|last9=Levantesi|first9=Giacomo|last10=Maggioni|first10=Aldo Pietro|last11=Mantini|first11=Loredana|last12=Marfisi|first12=Rosa Maria|last13=Mastrogiuseppe|first13=G.|last14=Mininni|first14=Nicola|last15=Nicolosi|first15=Gian Luigi|last16=Santini|first16=Massimo|last17=Schweiger|first17=Carlo|last18=Tavazzi|first18=Luigi|last19=Tognoni|first19=Gianni|last20=Tucci|first20=Corrado|last21=Valagussa|first21=Franco|title=Early Protection Against Sudden Death by n-3 Polyunsaturated Fatty Acids After Myocardial Infarction|journal=Circulation|volume=105|issue=16|year=2002|pages=1897–1903|issn=0009-7322|doi=10.1161/01.CIR.0000014682.14181.F2}}</ref>
* Another clinical trial showed using [[n–3 Fatty Acids]] was not effective in the reduction of the [[cardiovascular ]] event in high risk [[patients]].<ref>{{cite journal|title=n–3 Fatty Acids and Cardiovascular Outcomes in Patients with Dysglycemia|journal=New England Journal of Medicine|volume=367|issue=4|year=2012|pages=309–318|issn=0028-4793|doi=10.1056/NEJMoa1203859}}</ref>
* [[Statin]] clearly reduced [[mortality]] and [[SCD]] associated [[ischemic heart disease]].<ref name="LaRosaHe1999">{{cite journal|last1=LaRosa|first1=John C.|last2=He|first2=Jiang|last3=Vupputuri|first3=Suma|title=Effect of Statins on Risk of Coronary Disease|journal=JAMA|volume=282|issue=24|year=1999|pages=2340|issn=0098-7484|doi=10.1001/jama.282.24.2340}}</ref>
* Supressing [[plaque rupture]] or direct [[cardiovascular]] effect are two mechanisms of decrease [[ventricular arrhythmia]] by [[statin]].
* [[Statin]] is effective in prevention of [[ventricular arrhythmia]] in [[ischemic heart disease]], however, the role of [[statine]] in reducing [[SCD]] in [[heart failure]] [[ICD]] [[patients]] is not clearly explained.<ref name="pmid18757089">{{cite journal |vauthors=Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG, Latini R, Lucci D, Nicolosi GL, Porcu M, Tognoni G |title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial |journal=Lancet |volume=372 |issue=9645 |pages=1231–9 |date=October 2008 |pmid=18757089 |doi=10.1016/S0140-6736(08)61240-4 |url=}}</ref>

==Specific recommendation==
* The mainstay of therapy in [[heart failure]] reduced [[EF]] for prevention of [[SCD]] and [[ventricular arrhythmia]] is the following:
* [[Beta blocker]]s with benefit for preventing of [[SCD]] by reducing [[sympathetic activity]] and [[ myocardial]] [[oxygen]] demand or countering [[electrical excitability]].
* [[Angiotensin-converting enzyme inhibitors]], or [[angiotensin-receptor blockers]] is effective by reducing [[myocardial oxygen demand]], [[preload]], [[afterload]], prevention the formation of [[angiotensin II]], and slowing the process of [[ventricular remodeling]] and [[fibrosis]].<ref name="pmid2057035">{{cite journal |vauthors=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong M |title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure |journal=N Engl J Med |volume=325 |issue=5 |pages=303–10 |date=August 1991 |pmid=2057035 |doi=10.1056/NEJM199108013250502 |url=}}</ref>
* [[Mineralocorticoid receptor antagonists]] decrease [[potassium loss]], [[decrease fibrosis]], and increase the [[myocardial]] uptake of [[norepinephrine]].
* Chronic [[Beta blocker]]s therapy in [[heart failure]] reduced [[EF]] was associated with reduced [[SCD]], [[ventricular arrhythmia]] and all cause [[mortality]].
*[[Bisoprolol]], [[carvedilol]], [[sustained-release metoprolol succinate]] decrease [[mortality]] in [[patients]] with [[heart failure]] reduced [[EF]].<ref name="pmid10023943">{{cite journal |vauthors= |title=The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial |journal=Lancet |volume=353 |issue=9146 |pages=9–13 |date=January 1999 |pmid=10023943 |doi= |url=}}</ref><ref name="pmid11356434">{{cite journal |vauthors=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=Lancet |volume=357 |issue=9266 |pages=1385–90 |date=May 2001 |pmid=11356434 |doi=10.1016/s0140-6736(00)04560-8 |url=}}</ref><ref name="pmid10714728">{{cite journal |vauthors=Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P |title=Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group |journal=JAMA |volume=283 |issue=10 |pages=1295–302 |date=March 2000 |pmid=10714728 |doi=10.1001/jama.283.10.1295 |url=}}</ref>
* [[ACEI]] and [[mineralocorticoid-receptor antagonists]] ([[spironolactone]], [[eplerenone]]) reduce [[mortality]] and [[SCD]] in [[patients]] with severe [[heart failure]]. <ref name="pmid10471456">{{cite journal |vauthors=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J |title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators |journal=N Engl J Med |volume=341 |issue=10 |pages=709–17 |date=September 1999 |pmid=10471456 |doi=10.1056/NEJM199909023411001 |url=}}</ref>
==Management of [[patients]] with Polymorphic [[Ventricular arrhythmia]]==
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}
==Management of sustained monomorphic [[ventricular tachycardia]]==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}
==Management of electrical storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Quinidine]] ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Refractory electerical storm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Autonomic modulation]] may be considered in [[patients]] with [[electrical storm]] refractory to medical therapy and in whom [[catheter ablation]] is
ineffective or not possible 
❑ [[Mechanical circulatory support]] may be considered in the management of drug-refractory [[electrical storm]] and [[cardiogenic
shock]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== Recommendations for treatment with [[heart failure]] medication ==

{| class="wikitable"
|-
| Colspan="1" style="text-align:center; background:LightGreen"|[[ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| Bgcolor="LightGreen"|<nowiki>"</nowiki>[[Optimal medical treatment]] including [[ACE-I]]/[[ARB]]/ [[ARNIs]], [[mineralocorticoid receptor antagonist]], [[beta-blockers]], and [[SGLT2]] inhibitors is indicated in all [[heart failure]] [[patients]] with reduced [[EF]]''' ([[ESC guidelines classification scheme#Level of Evidence|Level of Evidence A]])<nowiki>"</nowiki>''
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== Notes==
* The most common cause of cardiac arrest is [[VF]], [[pulseless VT]], severe [[bradycardia]], and [[asystole]].
* Survival in the presence of [[VF]], [[VT]] is better than [[bradycardia]], [[asystole]] manifestation.<ref name="ZipesCamm2006">{{cite journal|last1=Zipes|first1=Douglas P.|last2=Camm|first2=A. John|last3=Borggrefe|first3=Martin|last4=Buxton|first4=Alfred E.|last5=Chaitman|first5=Bernard|last6=Fromer|first6=Martin|last7=Gregoratos|first7=Gabriel|last8=Klein|first8=George|last9=Moss|first9=Arthur J.|last10=Myerburg|first10=Robert J.|last11=Priori|first11=Silvia G.|last12=Quinones|first12=Miguel A.|last13=Roden|first13=Dan M.|last14=Silka|first14=Michael J.|last15=Tracy|first15=Cynthia|title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=114|issue=10|year=2006|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.178233}}</ref>
* Factors associated with better [[survival]] include rapid [[defibrillation]] and initiation of [[CPR ]] for a witnessed [[cardiac arrest]].
* [[Survival]] in [[patients]] with [[cardiac arrest]] decreases rapidly after the initial 2 minutes from the onset of [[cardiac arrest]], by 4 to 5 minutes, survival may be ≤25%, and by 10 minutes it is 0%.<ref name="SassonRogers2010">{{cite journal|last1=Sasson|first1=Comilla|last2=Rogers|first2=Mary A.M.|last3=Dahl|first3=Jason|last4=Kellermann|first4=Arthur L.|title=Predictors of Survival From Out-of-Hospital Cardiac Arrest|journal=Circulation: Cardiovascular Quality and Outcomes|volume=3|issue=1|year=2010|pages=63–81|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.109.889576}}</ref>
* Among [[patients]] with witnessed [[cardiac arrest]] due to initial shock-refractory [[VF]] or pulseless [[VT]], administration of [[amiodarone]] improved survival to hospital discharge compared with placebo in the setting of out-of-hospital [[cardiac arrest]].
* Administration of [[procainamide]] in out-of-hospital cardiac arrest due to [[VF]] or pulseless [[VT]] was correlated with more [[shocks]], more [[pharmacologic]] interventions, longer [[resuscitation]] times, and lower [[survival]].<ref name="Connolly2000">{{cite journal|last1=Connolly|first1=S|title=Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials|journal=European Heart Journal|volume=21|issue=24|year=2000|pages=2071–2078|issn=0195668X|doi=10.1053/euhj.2000.2476}}</ref>
* If left untreated, [[VF]] and pulseless monomorphic or polymorphic [[VT]], causes [[loss of consciousness]] and leads to [[death]].
* A short time to [[direct current cardioversion]] is the major determinant of [[survival]], and [[defibrillation]] should be performed as [[quickly]] as possible.
* [[CPR]] should be continued until restoration a [[perusing]] [[rhythm]].
* If [[defibrillation ]] failed to returning spontaneous [[circulation]], [[advanced cardiovascular life support]] should be followed.
* In unstable [[patients]] suspected [[coronary artery occlusion]] led to [[cardiac arrest]], emergency [[coronary angiography ]] should be considered rather than later in the [[hospital]] regardless the [[patient]] is [[comatose]] or [[awake]].<ref name="SpauldingJoly1997">{{cite journal|last1=Spaulding|first1=Christian M.|last2=Joly|first2=Luc-Marie|last3=Rosenberg|first3=Alain|last4=Monchi|first4=Mehran|last5=Weber|first5=Simon N.|last6=Dhainaut|first6=Jean-François A.|last7=Carli|first7=Pierre|title=Immediate Coronary Angiography in Survivors of Out-of-Hospital Cardiac Arrest|journal=New England Journal of Medicine|volume=336|issue=23|year=1997|pages=1629–1633|issn=0028-4793|doi=10.1056/NEJM199706053362302}}</ref><ref name="ZanuttiniArmellini2012">{{cite journal|last1=Zanuttini|first1=Davide|last2=Armellini|first2=Ilaria|last3=Nucifora|first3=Gaetano|last4=Carchietti|first4=Elio|last5=Trillò|first5=Giulio|last6=Spedicato|first6=Leonardo|last7=Bernardi|first7=Guglielmo|last8=Proclemer|first8=Alessandro|title=Impact of Emergency Coronary Angiography on In-Hospital Outcome of Unconscious Survivors After Out-of-Hospital Cardiac Arrest|journal=The American Journal of Cardiology|volume=110|issue=12|year=2012|pages=1723–1728|issn=00029149|doi=10.1016/j.amjcard.2012.08.006}}</ref>
* [[Coronary]] lesion requiring [[percutaneous coronary intervention]] was found in one-third of [[patients]] with [[out-of-hospital cardiac arrest]] without ST elevation in [[ECG]]. The outcome was reasonable. <ref name="DumasBougouin2016">{{cite journal|last1=Dumas|first1=Florence|last2=Bougouin|first2=Wulfran|last3=Geri|first3=Guillaume|last4=Lamhaut|first4=Lionel|last5=Rosencher|first5=Julien|last6=Pène|first6=Frédéric|last7=Chiche|first7=Jean-Daniel|last8=Varenne|first8=Olivier|last9=Carli|first9=Pierre|last10=Jouven|first10=Xavier|last11=Mira|first11=Jean-Paul|last12=Spaulding|first12=Christian|last13=Cariou|first13=Alain|title=Emergency Percutaneous Coronary Intervention in Post–Cardiac Arrest Patients Without ST-Segment Elevation Pattern|journal=JACC: Cardiovascular Interventions|volume=9|issue=10|year=2016|pages=1011–1018|issn=19368798|doi=10.1016/j.jcin.2016.02.001}}</ref>

* In the presence of incessant [[VT]], [[amiodarone]] was more effective than [[lidocaine]] and improved survival at 24 hours.<ref name="SombergBailin2002">{{cite journal|last1=Somberg|first1=John C|last2=Bailin|first2=Steven J|last3=Haffajee|first3=Charles I|last4=Paladino|first4=Walter P|last5=Kerin|first5=Nicholas Z|last6=Bridges|first6=Duane|last7=Timar|first7=Sandor|last8=Molnar|first8=Janos|title=Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia|journal=The American Journal of Cardiology|volume=90|issue=8|year=2002|pages=853–859|issn=00029149|doi=10.1016/S0002-9149(02)02707-8}}</ref>

* [[Procainamide]] is superior to [[lidocaine]] in the setting of recurrent stable hemodynamic [[VT]], and also preferred in the absent evidence of acute[[ MI]], or [[Long QTC]] on [[ECG]].<ref name="Gorgelsvan den Dool1996">{{cite journal|last1=Gorgels|first1=Anton P.M.|last2=van den Dool|first2=Adri|last3=Hofs|first3=Anton|last4=Mulleneers|first4=Rob|last5=Smeets|first5=Joep L.R.M.|last6=Vos|first6=Marc A.|last7=Wellens|first7=Hein J.J.|title=Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia|journal=The American Journal of Cardiology|volume=78|issue=1|year=1996|pages=43–46|issn=00029149|doi=10.1016/S0002-9149(96)00224-X}}</ref>

* [[lidocaine]] was less effective than [[amiodarone]] to improve [[hospital]] admission after [[out-of-hospital cardiac arrest]] due to shock-refractory [[VF]] or polymorphic [[VT]], but there were no differences between the two [[medications]] in [[survival]] to [[hospital]] discharge.
*[[Lidocaine]] improved [[survival]] to [[hospital]] discharge in witnessed [[SCA]] due to initial shock-refractory [[VF]] or pulseless [[VT]].
* Administration of [[beta blocker]] in [[patients]] with recent [[MI]] was associated with reduced [[VF]] and better [[survival]].
* If [[VT]], [[VF]] storm is refractory to [[amiodarone]], [[lidocaine]], or frequent [[cardioversion]], administration of [[betablocker]] has been shown improved [[survival]] and finally reducing [[sympathetic]] tone by [[sedation]] and [[general anesthesia]] are recommended.
* Administration of high-dose [[epinephrine]] ( 0.1 to 0.2 mg/kg IV) in [[out-of-hospital cardiac arrest]] unresponsive to [[defibrillation]], improved survival to [[hospital]] admission, but there was no difference compared to standard-dose [[epinephrine]] in survival to hospital discharge or long term survival compared with standard-dose [[epinephrine]] (1 mg given [[intravenously]] or intraosseously every 3 to 5 minutes).<ref name="pmid1433686">{{cite journal |vauthors=Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J |title=A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest |journal=JAMA |volume=268 |issue=19 |pages=2667–72 |date=November 1992 |pmid=1433686 |doi= |url=}}</ref>
* Administration of [[vasopressin]] is no longer recommended in the most recent [[advanced cardiovascular life support]] guideline.<ref name="LinkBerkow2015">{{cite journal|last1=Link|first1=Mark S.|last2=Berkow|first2=Lauren C.|last3=Kudenchuk|first3=Peter J.|last4=Halperin|first4=Henry R.|last5=Hess|first5=Erik P.|last6=Moitra|first6=Vivek K.|last7=Neumar|first7=Robert W.|last8=O’Neil|first8=Brian J.|last9=Paxton|first9=James H.|last10=Silvers|first10=Scott M.|last11=White|first11=Roger D.|last12=Yannopoulos|first12=Demetris|last13=Donnino|first13=Michael W.|title=Part 7: Adult Advanced Cardiovascular Life Support|journal=Circulation|volume=132|issue=18 suppl 2|year=2015|pages=S444–S464|issn=0009-7322|doi=10.1161/CIR.0000000000000261}}</ref>

* Intravenous [[magnesium]] is advised in the presence of [[hypokalemia]] or [[medication]]-induced [[torsades de pointed]] by suppression of early and [[late after depolarization]], and inhibition of [[calcium]] flux into [[cardiomyocytes]].
* Using intravenous [[magnesium]] during in-hospital or [[out-of-hospital cardiac arrest]] or refractory [[VF]] was not associated with restoration of [[circulation]] or [[survival]] benefit.<ref name="Hassan2002">{{cite journal|last1=Hassan|first1=T B|title=A randomised trial to investigate the efficacy of magnesium sulphate for refractory ventricular fibrillation|journal=Emergency Medicine Journal|volume=19|issue=1|year=2002|pages=57–62|issn=14720205|doi=10.1136/emj.19.1.57}}</ref>

* Administration The [[lidocaine]] and [[procainamide]] routinely after [[MI]] for suppression of [[ventricular arrhythmia]] was associated with increased [[mortality]], however,
use of [[beta blockers]] lessened [[mortality]] rate.<ref name="pmid8371471">{{cite journal |vauthors=Teo KK, Yusuf S, Furberg CD |title=Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. An overview of results from randomized controlled trials |journal=JAMA |volume=270 |issue=13 |pages=1589–95 |date=October 1993 |pmid=8371471 |doi= |url=}}</ref>
* Prophylactic use of Higher dose [[amiodarone]] after [[MI]] increase mortality, whereas moderate dose [[amiodarone]] was not superior to placebo.<ref name="Elizari2000">{{cite journal|last1=Elizari|first1=M|title=Morbidity and mortality following early administration of amiodarone in acute myocardial infarction|journal=European Heart Journal|volume=21|issue=3|year=2000|pages=198–205|issn=0195668X|doi=10.1053/euhj.1999.1687}}</ref>

* Every [[wide QRS tachycardia]] in the presence of [[structural heart disease]] should be presumed [[VT]] until proven otherwise such as [[SVT]] with aberrancy.
* Administration of [[verapamil]] in [[wide QRS tachycardia]] may lead to severe [[hypotension]] and [[syncope]] and should be avoided.
* The specific type of [[VT]] is [[verapamil]]-[[sensitive VT]] ([[interfascicular reentry]]) with [[structurally normal heart]], but it is important to notify that the recognition of this [[rhythm]] is difficult at initial presentation.<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>

{{familytree/start| | | | | | | | | | | | | |}}
{{familytree| | | | | | | | | | | A01 | | A01=Sustained monomorphic [[VT]]}}
{{familytree| | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | B01 | | | | | |B01=Hemodynamic stability}}
{{familytree| | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | C01 | | | | | | | | | | | |C02|C01=Stable|C02=Unstable}}
{{familytree| | | | |!| | | | | | | | | | | | | |!| }}
{{familytree| | | | D01 | | | | | | | | | | | |D02|D01=12-Lead [[ECG]], [[history]], [[physical exam]]|D02=[[Dirrect current cardioversion]],[[ACLS]]}}
{{familytree| | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{familytree| | | | E01 |,|-|E00|-|-|-|-|-|-|-|F02| | | | | | E01=Notifying disease causing [[VT]]|E00= Cardioversion(class1) |F02= [[VT]] termination}}
{{familytree| | | | |!| |!| |!| | | | | | | |,|-|^|-|.| | | | | }}
{{familytree| | | | F01 |+|-|F00| | | | | |S02| | S03| | |F01=[[Structural heart disease]]|F00=Intravenous [[ procainamide]] (class2a)|S02=Yes, therapy of underlying [[heart]] disease|S03=NO, [[cardioversion]] (class1)}}
{{familytree| | | | |!| |!| |!| | | | | | | | | | | |!| | | | |}}
{{familytree| | | | L01 |`|-|L00| | | | | | | | | P01 | | | | | L00= Intravenous [[amiodarone]] or [[sotalole]] (class2b)|L01= NO, [[Ideopathic VT]]|P01=[[VT]] termination}}
{{familytree| | | | |!| | | | | | | | | | | | | | |!| | | | | |}}
{{familytree| | | | S01 | | | | | | | | | | | | | |!| | | | | |S01=[[Verapamil]] sensitive [[VT]]: [[Verapamil]] outflow tract [[VT]]: [[betablocker]] (class2a) |}}
{{familytree| | |,|-|^|-|.| | | | | | | | | | |,|-|^|-|.| | | |}}
{{familytree| | |N01| |N02| | | | | | | | | Q01| | Q02| | | | | N01= Effective| N02=Non effective: [[cardioversion]]|Q01= Yes,therapy of underlying heart disease|Q02=NO, [[Sedation]] ,[[anesthesia]], reassessing [[antiarrhythmic]] therapy, repeating [[cardioversion]]}}
{{familytree| | |!| | | | | | | | | | | | | | | | | | |!| | | |}}
{{familytree| | |M01| | | | | | | | | | | | | | | | | R01| | | |M01= Therapy to prevent recurrence of [[VT]] |R01= No [[VT]] termination}}
{{familytree|,|-|^|-|.| | | | | | | | | | | | | | | | |!| | | |}}
{{familytree|!| | | |!| | | | | | | | | | | | | | | | |R02| | |R02= [[Catheter ablation]] (class1) |}}
{{familytree|G01| |G02| | | | | | | | | | | | | | | | | | | | | G01=Catheter ablation (class1)| G02= [[ Verapamil]] , [[betablocker]] (class2a)}}
{{familytree| | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2017 AHA/ACC/HRS Guideline
|-
|}

==Comments==

*Common [[antiarrhythmic]] medications for supression of [[ventricular arrhythmia]] include [[amiodarone]], [[sotalol]], and occasionally [[mexilletine]], [[quinidine]],[[ranolazine]].<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref><ref name="KetteringMewis2002">{{cite journal|last1=Kettering|first1=Klaus|last2=Mewis|first2=Christian|last3=Dornberger|first3=Volker|last4=Vonthein|first4=Reinhard|last5=Bosch|first5=Ralph F.|last6=Kuhlkamp|first6=Volker|title=Efficacy of Metoprolol and Sotalol in the Prevention of Recurrences of Sustained Ventricular Tachyarrhythmias in Patients with an Implantable Cardioverter Defibrillator|journal=Pacing and Clinical Electrophysiology|volume=25|issue=11|year=2002|pages=1571–1576|issn=0147-8389|doi=10.1046/j.1460-9592.2002.01571.x}}</ref>
* [[Amiodarone]] is more effective than [[sotalol]] but discontinuation may happen during 12-24 months of use due to adverse effects.<ref name="Connolly2006">{{cite journal|last1=Connolly|first1=Stuart J.|title=Comparison of β-Blockers, Amiodarone Plus β-Blockers, or Sotalol for Prevention of Shocks From Implantable Cardioverter Defibrillators<SUBTITLE>The OPTIC Study: A Randomized Trial</SUBTITLE>|journal=JAMA|volume=295|issue=2|year=2006|pages=165|issn=0098-7484|doi=10.1001/jama.295.2.165}}</ref>
* Contraindication of [[sotalol]] may include severely reduced [[LVEF]] <20% due to its negative inotropic effects and the risk of [[torsades de pointed]].
* In [[patients]] with [[prior]] [[MI]] and recurrent sustained [[monomorphic VT]] despite receiving [[amiodarone]] , [[catheter ablation]] was related to better outcome.<ref name="TungVaseghi2015">{{cite journal|last1=Tung|first1=Roderick|last2=Vaseghi|first2=Marmar|last3=Frankel|first3=David S.|last4=Vergara|first4=Pasquale|last5=Di Biase|first5=Luigi|last6=Nagashima|first6=Koichi|last7=Yu|first7=Ricky|last8=Vangala|first8=Sitaram|last9=Tseng|first9=Chi-Hong|last10=Choi|first10=Eue-Keun|last11=Khurshid|first11=Shaan|last12=Patel|first12=Mehul|last13=Mathuria|first13=Nilesh|last14=Nakahara|first14=Shiro|last15=Tzou|first15=Wendy S.|last16=Sauer|first16=William H.|last17=Vakil|first17=Kairav|last18=Tedrow|first18=Usha|last19=Burkhardt|first19=J. David|last20=Tholakanahalli|first20=Venkatakrishna N.|last21=Saliaris|first21=Anastasios|last22=Dickfeld|first22=Timm|last23=Weiss|first23=J. Peter|last24=Bunch|first24=T. Jared|last25=Reddy|first25=Madhu|last26=Kanmanthareddy|first26=Arun|last27=Callans|first27=David J.|last28=Lakkireddy|first28=Dhanunjaya|last29=Natale|first29=Andrea|last30=Marchlinski|first30=Francis|last31=Stevenson|first31=William G.|last32=Della Bella|first32=Paolo|last33=Shivkumar|first33=Kalyanam|title=Freedom from recurrent ventricular tachycardia after catheter ablation is associated with improved survival in patients with structural heart disease: An International VT Ablation Center Collaborative Group study|journal=Heart Rhythm|volume=12|issue=9|year=2015|pages=1997–2007|issn=15475271|doi=10.1016/j.hrthm.2015.05.036}}</ref>
* Recurrent [[VT]] after [[catheter ablation]] is associated with increased [[mortality]].
* Administration of [[encainide]] or [[flecainide]] for suppression of [[PVC]]s and non sustained [[VT]] in post [[MI]] period was associated with increased [[mortality]] and non fatal [[cardiac arrest]].<ref name="EchtLiebson1991">{{cite journal|last1=Echt|first1=Debra S.|last2=Liebson|first2=Philip R.|last3=Mitchell|first3=L. Brent|last4=Peters|first4=Robert W.|last5=Obias-Manno|first5=Dulce|last6=Barker|first6=Allan H.|last7=Arensberg|first7=Daniel|last8=Baker|first8=Andrea|last9=Friedman|first9=Lawrence|last10=Greene|first10=H. Leon|last11=Huther|first11=Melissa L.|last12=Richardson|first12=David W.|title=Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo|journal=New England Journal of Medicine|volume=324|issue=12|year=1991|pages=781–788|issn=0028-4793|doi=10.1056/NEJM199103213241201}}</ref>

* In survivors of [[SCA]] use of [[Propafenone]] increased [[mortality]] in comparison with [[beta-blockers]], [[amiodarone]], and the [[ICD]].
* In [[patients]] with prior [[ MI]], Sustained [[monomorphic VT ]] can be due to scar-related reentry, but not acute [[ischemia]].
* [[Antiarrhythmic]] medications or [[ablation]] may be needed to prevent recurrence of [[VT]] in scar-related settings.<ref name="BrugadaAguinaga2001">{{cite journal|last1=Brugada|first1=Josep|last2=Aguinaga|first2=Luis|last3=Mont|first3=Lluı́s|last4=Betriu|first4=Amadeu|last5=Mulet|first5=Jaume|last6=Sanz|first6=Ginés|title=Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction: effects on the electrophysiologic substrate and outcome|journal=Journal of the American College of Cardiology|volume=37|issue=2|year=2001|pages=529–533|issn=07351097|doi=10.1016/S0735-1097(00)01133-5}}</ref>

* Revascularization is recommended in the setting of [[ischemia]] for prevention of [[VF]], [[polymorphic VT]]. <ref name="BerntsenGunnes1993">{{cite journal|last1=Berntsen|first1=R. F.|last2=Gunnes|first2=P.|last3=Lie|first3=M.|last4=Rasmussen|first4=K.|title=Surgical revascularization in the treatment of ventricular tachycardia and fibrillation exposed by exercise-induced ischaemia|journal=European Heart Journal|volume=14|issue=10|year=1993|pages=1297–1303|issn=0195-668X|doi=10.1093/eurheartj/14.10.1297}}</ref>

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for treatment of recurrent ventricular tachycardia in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Medications ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[IHD]] and recurrent symptomatic [[ventricular tachycardia]] and frequent [[ICD]] shocks despite programming, [[betablocker]], [[sotalol]], [[amiodarone]] is recommended for supression of [[arrhythmia]] 
❑ In [[patients]] with period [[MI]] and presence of [[VT]] storm refractory to [[amiodarone]] or other [[antiarrhythmic]] drugs, [[catheter ablation ]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation ]] can be the first line therapy for recurrent sustained [[monomorphic VT]] in [[IHD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Class IC [[antiarrhythmic ]] drugs ([[flecainide]], [[propafenone]] ) is harmful for supression of [[ventricular tachycardia]] in [[patients]] with [[perior MI]] 
❑ In [[patients]] with incessant [[VT]]/[[VF]], after controlling [[tachyarrhythmia]] [[ICD]] should be implanted due to avoiding of repeated [[ICD]] [[shocks]] 
❑ In [[patients]] with recurrent [[monomorphic VT]] , only [[revascularization]] is ineffective for preventing of [[tachyarrhythmia]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
|-
|}

==Message==

*Although [[ICD]] reduced [[mortality]], painful [[ICD]] shocks can affect on the [[quality of life]] and increases [[morbidity]].
*The frequent of [[ICD]] shocks lessened by [[amiodarone]] plus [[beta blocker]] compared with [[sotalol]] but at the expense of increased risk of [[amiodarone]]-related adverse effects.<ref name="Connolly2006">{{cite journal|last1=Connolly|first1=Stuart J.|title=Comparison of β-Blockers, Amiodarone Plus β-Blockers, or Sotalol for Prevention of Shocks From Implantable Cardioverter Defibrillators<SUBTITLE>The OPTIC Study: A Randomized Trial</SUBTITLE>|journal=JAMA|volume=295|issue=2|year=2006|pages=165|issn=0098-7484|doi=10.1001/jama.295.2.165}}</ref>
* All types of non-ischemic [[cardiomyopathy]] can produce scar-related [[VT]] especially [[cardiac]] [[sarcoidosis]].<ref name="NaruseSekiguchi2014">{{cite journal|last1=Naruse|first1=Yoshihisa|last2=Sekiguchi|first2=Yukio|last3=Nogami|first3=Akihiko|last4=Okada|first4=Hiroyuki|last5=Yamauchi|first5=Yasuteru|last6=Machino|first6=Takeshi|last7=Kuroki|first7=Kenji|last8=Ito|first8=Yoko|last9=Yamasaki|first9=Hiro|last10=Igarashi|first10=Miyako|last11=Tada|first11=Hiroshi|last12=Nitta|first12=Junichi|last13=Xu|first13=Dongzhu|last14=Sato|first14=Akira|last15=Aonuma|first15=Kazutaka|title=Systematic Treatment Approach to Ventricular Tachycardia in Cardiac Sarcoidosis|journal=Circulation: Arrhythmia and Electrophysiology|volume=7|issue=3|year=2014|pages=407–413|issn=1941-3149|doi=10.1161/CIRCEP.113.000734}}</ref>

* [[Catheter ablation]] can be used for treatment of [[scar related]] [[VT]] in [[non-ischemic cardiomyopathy]].<ref name="DinovFiedler2014">{{cite journal|last1=Dinov|first1=Borislav|last2=Fiedler|first2=Lukas|last3=Schönbauer|first3=Robert|last4=Bollmann|first4=Andreas|last5=Rolf|first5=Sascha|last6=Piorkowski|first6=Christopher|last7=Hindricks|first7=Gerhard|last8=Arya|first8=Arash|title=Outcomes in Catheter Ablation of Ventricular Tachycardia in Dilated Nonischemic Cardiomyopathy Compared With Ischemic Cardiomyopathy|journal=Circulation|volume=129|issue=7|year=2014|pages=728–736|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.113.003063}}</ref>
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for treatment of recurrent ventricular tachycardia in non-ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Amiodarone, sotalol ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Amiodarone]] or [[sotalol]] is recommended in the presensence of recurrent [[ventricular arrhythmia]] and frequent [[ICD]] shocks despite optimal programming or [[beta blocker]] therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In the setting of frequent [[ventricular arrhythmia]] despite optimal [[ICD]] programming or failed [[antiarrhythmic]] medications, [[catheter ablation]] is recommended 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
|-
|}

==References==
{{Reflist|2}}
[[Category:Best pages]]
[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date]]

[[Category:Disease]]
[[Category:Electrophysiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]

{{WS}}
{{WH}}

Ventricular tachycardia medical therapy

2022-09-16T05:07:48Z

Sara Zand: /* Notes */

__NOTOC__
{{Ventricular tachycardia}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}, [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]
==Overview==
The mainstay of medical therapy in hemodynamic stable [[VT]] is suppression of [[tachyarrhythmia]] with [[antiarrhythmic]] [[medications]] such as [[amiodarone]], [[sotalol]], [[lidocaine]], [[betablocker]] alongside with correction of [[hypokalemia]], [[hypomagnesemia]] and [[hypocalcemia]]. In addition, treating the underlying causes of [[VT]] including
[[ischemic heart disease]] or [[decompensated heart failure]]
are warranted.

==Medical Therapy==
Common [[medications]] for treatment of [[VT]] include:<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref>
==[[Antiarrhythmic]] [[medications]]==
<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>

===[[Sodium channel blocker]]===
* In [[patients]] with [[ischemic heart disease]], chronic use of [[sodium channel blocker]] increased risk of [[mortality]].
* Some [[sodium channel blockers]] with benefit in special setting include the following:
:* [[Lidocaine]] (class1) for [[patients]] with refractory [[VT]], [[cardiac arrest]] (especially [[witnessed]]) <ref name="KudenchukBrown2016">{{cite journal|last1=Kudenchuk|first1=Peter J.|last2=Brown|first2=Siobhan P.|last3=Daya|first3=Mohamud|last4=Rea|first4=Thomas|last5=Nichol|first5=Graham|last6=Morrison|first6=Laurie J.|last7=Leroux|first7=Brian|last8=Vaillancourt|first8=Christian|last9=Wittwer|first9=Lynn|last10=Callaway|first10=Clifton W.|last11=Christenson|first11=James|last12=Egan|first12=Debra|last13=Ornato|first13=Joseph P.|last14=Weisfeldt|first14=Myron L.|last15=Stiell|first15=Ian G.|last16=Idris|first16=Ahamed H.|last17=Aufderheide|first17=Tom P.|last18=Dunford|first18=James V.|last19=Colella|first19=M. Riccardo|last20=Vilke|first20=Gary M.|last21=Brienza|first21=Ashley M.|last22=Desvigne-Nickens|first22=Patrice|last23=Gray|first23=Pamela C.|last24=Gray|first24=Randal|last25=Seals|first25=Norman|last26=Straight|first26=Ron|last27=Dorian|first27=Paul|title=Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest|journal=New England Journal of Medicine|volume=374|issue=18|year=2016|pages=1711–1722|issn=0028-4793|doi=10.1056/NEJMoa1514204}}</ref>
:*Oral [[mexiletine]] for [[congenital long QT syndrome]]<ref name="MazzantiMaragna2016">{{cite journal|last1=Mazzanti|first1=Andrea|last2=Maragna|first2=Riccardo|last3=Faragli|first3=Alessandro|last4=Monteforte|first4=Nicola|last5=Bloise|first5=Raffaella|last6=Memmi|first6=Mirella|last7=Novelli|first7=Valeria|last8=Baiardi|first8=Paola|last9=Bagnardi|first9=Vincenzo|last10=Etheridge|first10=Susan P.|last11=Napolitano|first11=Carlo|last12=Priori|first12=Silvia G.|title=Gene-Specific Therapy With Mexiletine Reduces Arrhythmic Events in Patients With Long QT Syndrome Type 3|journal=Journal of the American College of Cardiology|volume=67|issue=9|year=2016|pages=1053–1058|issn=07351097|doi=10.1016/j.jacc.2015.12.033}}</ref>
:*[[Quinidine]] for [[patients]] with [[Brugada]] syndrome
:* [[Flecainide]] for [[patients]] with [[catecholaminergic polymorphic ventricular tachycardia]]<ref name="WatanabeChopra2009">{{cite journal|last1=Watanabe|first1=Hiroshi|last2=Chopra|first2=Nagesh|last3=Laver|first3=Derek|last4=Hwang|first4=Hyun Seok|last5=Davies|first5=Sean S|last6=Roach|first6=Daniel E|last7=Duff|first7=Henry J|last8=Roden|first8=Dan M|last9=Wilde|first9=Arthur A M|last10=Knollmann|first10=Björn C|title=Flecainide prevents catecholaminergic polymorphic ventricular tachycardia in mice and humans|journal=Nature Medicine|volume=15|issue=4|year=2009|pages=380–383|issn=1078-8956|doi=10.1038/nm.1942}}</ref>
::* Theses [[medications]] are useful in [[ICD]] [[patients]] with [[drug]] and ablation refractory [[VT]].

===[[Ranolazine]]===
:* A new [[antiangina]] drug approved by [[FDA]] with [[antiarrhythmic]] efficacy.
:*Mechanism of action is late [[sodium]] channel current blockade , blockade of the phase 3 [[repolarizing]] [[potassium]] current.
:* Reducion [[ICD]] shocks in drug resistant [[VT]], [[VF]]<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref>

:* Reducion [[VT]] in the first days after [[NSTEMI]] according to [[MERLIN TIMI-36]].<ref name="SciricaBraunwald2010">{{cite journal|last1=Scirica|first1=Benjamin M.|last2=Braunwald|first2=Eugene|last3=Belardinelli|first3=Luiz|last4=Hedgepeth|first4=Chester M.|last5=Spinar|first5=Jindrich|last6=Wang|first6=Whedy|last7=Qin|first7=Jie|last8=Karwatowska-Prokopczuk|first8=Ewa|last9=Verheugt|first9=Freek W.A.|last10=Morrow|first10=David A.|title=Relationship Between Nonsustained Ventricular Tachycardia After Non–ST-Elevation Acute Coronary Syndrome and Sudden Cardiac Death|journal=Circulation|volume=122|issue=5|year=2010|pages=455–462|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.110.937136}}</ref>

:* NO efficacy in reduction the fist [[VT]], [[VF]] in high risk [[patients]], but significant reduction of recurrent [[VT]], [[VF]] requiring [[ICD]] implantation.<ref name="ZarebaDaubert2018">{{cite journal|last1=Zareba|first1=Wojciech|last2=Daubert|first2=James P.|last3=Beck|first3=Christopher A.|last4=Huang|first4=David T.|last5=Alexis|first5=Jeffrey D.|last6=Brown|first6=Mary W.|last7=Pyykkonen|first7=Kathryn|last8=McNitt|first8=Scott|last9=Oakes|first9=David|last10=Feng|first10=Changyong|last11=Aktas|first11=Mehmet K.|last12=Ayala-Parades|first12=Felix|last13=Baranchuk|first13=Adrian|last14=Dubuc|first14=Marc|last15=Haigney|first15=Mark|last16=Mazur|first16=Alexander|last17=McPherson|first17=Craig A.|last18=Mitchell|first18=L. 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===[[Beta blocker]]===
:* First line therapy for the most of [[ventricular arrhythmia]] such as [[PVC]], [[VT]] because of safety and efficacy<ref name="ReiterReiffel1998">{{cite journal|last1=Reiter|first1=Michael J.|last2=Reiffel|first2=James A.|title=Importance of beta blockade in the therapy of serious ventricular arrhythmias|journal=The American Journal of Cardiology|volume=82|issue=4|year=1998|pages=9I–19I|issn=00029149|doi=10.1016/S0002-9149(98)00468-8}}</ref>

:* Supression of [[ventricular arrhythmia]] in [[structurally normal heart]].
:* Reducing all-cause mortality and [[SCD]] in [[patients]] with [[heart failure]] with reduced [[EF]]<ref name="pmid10376614">{{cite journal |vauthors= |title=Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) |journal=Lancet |volume=353 |issue=9169 |pages=2001–7 |date=June 1999 |pmid=10376614 |doi= |url=}}</ref>
:* Reducing [[mortality]] after [[MI]]
:* Increased [[mortality]] and risk of [[cardiogenic shock]] after [[MI]] in the presence of >70 years of age, symptoms <12 hours [[ST-elevation MI]] [[patients]], [[systolic blood pressure ]]<120 mm Hg, [[heart rate ]]>110 beat/min <ref name="KontosDiercks2011">{{cite journal|last1=Kontos|first1=Michael C.|last2=Diercks|first2=Debra B.|last3=Ho|first3=P. Michael|last4=Wang|first4=Tracy Y.|last5=Chen|first5=Anita Y.|last6=Roe|first6=Matthew T.|title=Treatment and outcomes in patients with myocardial infarction treated with acute β-blocker therapy: Results from the American College of Cardiology’s NCDR®|journal=American Heart Journal|volume=161|issue=5|year=2011|pages=864–870|issn=00028703|doi=10.1016/j.ahj.2011.01.006}}</ref>
:*Increased [[antiarrhythmic]] effect of membrane stabilizing drug in [[malignant]] [[VT]].<ref name="HirsowitzPodrid1986">{{cite journal|last1=Hirsowitz|first1=Geoffrey|last2=Podrid|first2=Philip J.|last3=Lampert|first3=Steven|last4=Stein|first4=Joseph|last5=Lown|first5=Bernard|title=The role of beta blocking agents as adjunct therapy to membrane stabilizing drugs in malignant ventricular arrhythmia|journal=American Heart Journal|volume=111|issue=5|year=1986|pages=852–860|issn=00028703|doi=10.1016/0002-8703(86)90633-2}}</ref>
:*[[Nadolol]], [[propranolol]]: first-line therapy for some [[cardiac]] channelopathies such as [[long QT syndrome]], [[catecholaminergic polymorphic ventricular tachycardia]]

===[[Amiodarone]], [[sotalol]]===
* [[ Amiodarone]] is a multichannel blocker by blockade of [[beta receptors]], [[sodium]], [[calcium]], [[potassium]] currents
* NO survival benefit from [[amiodarone]] compared with placebo in [[patients]] with [[LV dysfunction]] due to [[prior MI]] and [[non ischemic cardiomyopathy]] according to [[SCD-HeFT]]<ref name="BardyLee2005">{{cite journal|last1=Bardy|first1=Gust H.|last2=Lee|first2=Kerry L.|last3=Mark|first3=Daniel B.|last4=Poole|first4=Jeanne E.|last5=Packer|first5=Douglas L.|last6=Boineau|first6=Robin|last7=Domanski|first7=Michael|last8=Troutman|first8=Charles|last9=Anderson|first9=Jill|last10=Johnson|first10=George|last11=McNulty|first11=Steven E.|last12=Clapp-Channing|first12=Nancy|last13=Davidson-Ray|first13=Linda D.|last14=Fraulo|first14=Elizabeth S.|last15=Fishbein|first15=Daniel P.|last16=Luceri|first16=Richard M.|last17=Ip|first17=John H.|title=Amiodarone or an Implantable Cardioverter–Defibrillator for Congestive Heart Failure|journal=New England Journal of Medicine|volume=352|issue=3|year=2005|pages=225–237|issn=0028-4793|doi=10.1056/NEJMoa043399}}</ref>
* Use of [[amiodarone]] after [[MI]] in patients with NYHA 3 [[symptoms]] was associated with increased risk of [[mortality]].<ref name="ThomasAl-Khatib2008">{{cite journal|last1=Thomas|first1=Kevin L.|last2=Al-Khatib|first2=Sana M.|last3=Lokhnygina|first3=Yuliya|last4=Solomon|first4=Scott D.|last5=Kober|first5=Lars|last6=McMurray|first6=John J.V.|last7=Califf|first7=Robert M.|last8=Velazquez|first8=Eric J.|title=Amiodarone use after acute myocardial infarction complicated by heart failure and/or left ventricular dysfunction may be associated with excess mortality|journal=American Heart Journal|volume=155|issue=1|year=2008|pages=87–93|issn=00028703|doi=10.1016/j.ahj.2007.09.010}}</ref>
* In [[patients]] with [[nonischemic cardiomyopathy]] ([[LVEF]]<40%), use of [[amiodarone]] reduced the risk of [[SCD]] (with low quality of support of article), but there was NO benefit of using [[amiodarone]] for [[secondary prevention]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>

* Infused [[amiodarone]] during [[cardiopulmonary resuscitation]] prevents recurrent [[VT]], [[VF]].<ref name="KudenchukCobb1999">{{cite journal|last1=Kudenchuk|first1=Peter J.|last2=Cobb|first2=Leonard A.|last3=Copass|first3=Michael K.|last4=Cummins|first4=Richard O.|last5=Doherty|first5=Alidene M.|last6=Fahrenbruch|first6=Carol E.|last7=Hallstrom|first7=Alfred P.|last8=Murray|first8=William A.|last9=Olsufka|first9=Michele|last10=Walsh|first10=Thomas|title=Amiodarone for Resuscitation after Out-of-Hospital Cardiac Arrest Due to Ventricular Fibrillation|journal=New England Journal of Medicine|volume=341|issue=12|year=1999|pages=871–878|issn=0028-4793|doi=10.1056/NEJM199909163411203}}</ref>
* [[Amiodarone]] decreased risk of [[SCD]] and all-cause [[mortality ]] compared with [[betablocker]] or [[sotalol]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>
*Chronic use of [[amiodarone]] has adverse effect on [[lung]], [[liver]], [[thyroid]], [[skin]], and [[nervous system]].<ref name="ClaroCandia2015">{{cite journal|last1=Claro|first1=Juan Carlos|last2=Candia|first2=Roberto|last3=Rada|first3=Gabriel|last4=Baraona|first4=Fernando|last5=Larrondo|first5=Francisco|last6=Letelier|first6=Luz M|title=Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death|journal=Cochrane Database of Systematic Reviews|year=2015|issn=14651858|doi=10.1002/14651858.CD008093.pub2}}</ref>
* [[ECG]], [[liver function tests]], [[thyroid function tests]], [[chest x-ray]], and [[pulmonary function tests]] (including diffusing capacity of the [[lungs]] for [[carbon monoxide]]) is needed before administration of [[amiodarone]]. In case of [[pulmonary]] toxicity, [[chest CT scan]] should be done.<ref name="EpsteinOlshansky2016">{{cite journal|last1=Epstein|first1=Andrew E.|last2=Olshansky|first2=Brian|last3=Naccarelli|first3=Gerald V.|last4=Kennedy|first4=John I.|last5=Murphy|first5=Elizabeth J.|last6=Goldschlager|first6=Nora|title=Practical Management Guide for Clinicians Who Treat Patients with Amiodarone|journal=The American Journal of Medicine|volume=129|issue=5|year=2016|pages=468–475|issn=00029343|doi=10.1016/j.amjmed.2015.08.039}}</ref>
* Although [[sotalol]] suppressed [[ventricular arrhythmia]], it was associated with increased risk of [[mortality]] in [[heart failure]] [[patients]].<ref name="pmid7747682">{{cite journal |vauthors=Waldo AL, Camm AJ, deRuyter H, Freidman PL, MacNeil DJ, Pitt B, Pratt CM, Rodda BE, Schwartz PJ |title=Survival with oral d-sotalol in patients with left ventricular dysfunction after myocardial infarction: rationale, design, and methods (the SWORD trial) |journal=Am J Cardiol |volume=75 |issue=15 |pages=1023–7 |date=May 1995 |pmid=7747682 |doi=10.1016/s0002-9149(99)80717-6 |url=}}</ref>
* [[Sotalol]] may decrease [[defibrillation threshold]] and should be avoided in patients with [[LVEF]]< 20% due to decompensation of [[heart failure]].<ref name="Page2000">{{cite journal|last1=Page|first1=Richard L|title=Effects of antiarrhythmic medication on implantable cardioverter-defibrillator function|journal=The American Journal of Cardiology|volume=85|issue=12|year=2000|pages=1481–1485|issn=00029149|doi=10.1016/S0002-9149(00)00799-2}}</ref>

===[[ Calcium channel blocker]]===
* [[Non-dihydropyridines calcium channel blockers]] have no role in the treatment of most [[ventricular arrhythmia]]s.
* In [[patients]] with prior [[MI]], administration of intravenous [[verapamil]] for sustained [[VT]] has been associated with [[hemodynamic collapse ]].<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>
* [[Verapamil]] and [[diltiazem]] can be used for suppression of some [[VT]] originated outflow tract.<ref name="GillWard1992">{{cite journal|last1=Gill|first1=Jaswinder S.|last2=Ward|first2=David E.|last3=Camm|first3=A. John|title=Comparison of Verapamil and Diltiazem in the Suppression of Idiopathic Ventricular Tachycardia|journal=Pacing and Clinical Electrophysiology|volume=15|issue=11|year=1992|pages=2122–2126|issn=0147-8389|doi=10.1111/j.1540-8159.1992.tb03033.x}}</ref>
* Oral and intravenous [[verapamil ]] is effective for the treatment of idiopathic interfascicular reentrant left [[VT]] in [[patients]] with normal structurally [[heart]].<ref name="BadhwarScheinman2007">{{cite journal|last1=Badhwar|first1=Nitish|last2=Scheinman|first2=Melvin M.|title=Idiopathic Ventricular Tachycardia: Diagnosis and Management|journal=Current Problems in Cardiology|volume=32|issue=1|year=2007|pages=7–43|issn=01462806|doi=10.1016/j.cpcardiol.2006.10.002}}</ref>
*[[Non-dihydropyridines]] [[Calcium channel blockers]] should be avoided for converting [[VT]] in [[heart failure]] reduced [[EF]].

{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Arrhythmiac medication, class, dose}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF| Indication}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF| Receptor target}}
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF| Electrophysiologic effect}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Pharmacological characteristics}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Common advers effects}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Acebutolol]]
PO 200–1200 mg daily, up to 600 mg bid
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | B1, mild internistic [[sympathetic]] activity
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowing [[sinus rate]], increasing [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[haft life]] in [[renal]] impairment, metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[Dizziness]], [[fatigue]], [[anxiety]], [[impotence]], [[hyperesthesia]],[[hypoesthesia]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Amiodarone ]] (III)
IV:[[VF]]/[[pulseless VT]] arrest: 300 mg bolus, stable [[VT]]: 150-mg bolus then 1 mg/min x 6 h, then 0.5 mg/min x 18 h
PO: 400 mg q 8 to 12 h for 1–2 wk, then 300–400 mg daily; reduce dose to 200 mg daily if possible
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[INa]], [[ICa]], [[IKr]], [[IK1]], [[IKs]], [[Ito]], [[Beta receptor]], [[Alpha receptor]], [[nuclear T3]]
recepto
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QRS]] prolongation, [[QTc]] prolongation, increased [[AV ]] nodal refractoriness ,increased [[defibrilation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metabolism]]: [[hepatic]], half life: 26-107 days
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypotension]], [[bradycardia]], [[AV]] block, [[TdP]], slowing [[VT]] below programmed [[ICD]] detection rate, increased [[defibrillation threshold]], [[corneal microdeposits]], [[thyroid]] abnormalities, [[ataxia]], [[nausea]], [[emesis]], [[constipation]], [[photosensitivity]], [[skin]] discoloration, [[ataxia]], [[dizziness]], [[peripheral neuropathy]], [[tremor]], [[hepatitis]], [[cirrhosis]], [[pulmonary fibrosis]], [[pneumonitis]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Atenolol]] (II)
PO: 25–100 mg qd or bid
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[ARVC]], [[LQTS]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Beta 1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate ]],
increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[heart failure]], [[AV]] block, [[dizziness]], [[fatigue]], [[depression]], [[impotence]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bisoprolol]] (II)
PO: 2.5–10 mg once daily
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Beta 1 receptor]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV ]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Chest pain]], [[bradycardia]], [[AV]] block, [[Fatigue]], [[insomnia]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Carvedilol]] (II)
PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1]], [[Beta 2]], [[Alpha]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], [[syncope]], [[Hyperglycemia]], [[dizziness]], [[fatigue]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Carvedilol]] (II)
PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1]], [[Beta 2]], [[Alpha]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], [[syncope]], [[Hyperglycemia]], [[dizziness]], [[fatigue]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Diltiazem]] (IV)
IV: 5–10 mg,qd: 15–30 min, Extended release: PO: 120–360 mg/da, PO: 3.125–25 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[RVOT]] [[VT]], ideopathic left [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[ICa-L]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], slowed [[AV]] node conduction, [[PR]] prolongation
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[edema]], exacerbation of [[HF]] reduced [[EF]], [[Headache]], [[rash]], [[constipation]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Esmolol]] (II)
IV: 0.5 mg/kg bolus, 0.05 mg/kg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] node refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[RBC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[HF]], [[dizziness]], [[neusea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Flecainide]] (IC) PO: 50–200 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]] (in the absence of [[structural heart disease]]), [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]], [[IKur]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[PR]] interval, prolonged [[QRS]] duration, increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[RBC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Sinus node dysfunction]], [[AV]] block, [[drug]]-induced [[Brugada]] syndrome, [[monomorphic VT]] in patients with a [[myocardial]] scar, [[exacerbation]] of [[HFrEF]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Lidocaine]] (IB)
IV: 1 mg/kg bolus, 1–3 mg/min, 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg bolus every 5–10 min (max cumulative dose 3 mg/kg), maintenance infusion: 1–4 mg/min or starting 0.5 mg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slightly shortening of [[QTc]] interval
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]], prolonged half life in [[HF]], [[liver]] disease, [[shock]], severe [[renal]] disease
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hemodynamic collapse]], [[AV]] block, [[sinus arrest]], [[delirium]], [[psychosis]], [[seizure]], [[nausea]], [[tinnitus]], [[dyspnea]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metoprolol]] (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: None, Excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[dizziness]], [[fatigue]], [[diarrhea]], [[depression]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Metoprolol]] (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: None, Excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[AV]] block, [[dizziness]], [[fatigue]], [[diarrhea]], [[depression]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Mexiletine]] (IB), PO: 150–300 mg q 8 h or q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[VF]], [[Long QT]]3
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slightly shortening of [[QTc]] interval
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[HF]], [[AV]] block, [[lightheaded]], [[tremor]], [[ataxia]], [[paresthesias]], [[nausea]], [[blood dyscrasias]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Nadolol]] (II)
PO: 40–320 mg daily
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[LQTS]], [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]], excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[edema]], [[dizziness]], [[cold extremities]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procainamide]] (IA), IV: loading dose 10–17 mg/kg at 20–50 mg/min, maintenance dose: 1–4 mg/min, PO (SR preparation): 500–1250 mg q 6 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[LQTS]], [[CPVT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]], excretion: [[urine]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[edema]], [[dizziness]], [[cold extremities]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Propafenone]] (IC), PO: Immediate release 150–300 mg q 8 h, Extended release 225–425 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]] (in the absence of [[structural heart disease]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]], [[IKur]], [[ Beta receptor]], [[Alpha recept]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prolonged [[PR]] interval, prolonged [[QRS]] duration, increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[HF]], [[AV]] block, drug-induced [[Brugada ]] syndrome, [[ dizziness]], [[fatigue]], [[nausea]], [[diarrhea]], [[xerostomia]], [[tremor]], [[blurred vision]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Propranolol]] (II), IV: 1–3 mg q 5 min to a total of 5 mg, PO: Immediate release 10–40 mg q 6 h; Extended release 60–160 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[PVC]], [[Long QT]] syndrome
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Beta 1 ]], B2 , INa
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], increased [[AV]] nodal refractoriness
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[AV]] block, [[sleep disorder]], [[dizziness]], [[nightmares]], [[hyperglycemia]], [[diarrhea]], [[bronchospasm]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Quinidine]] (IA), PO: sulfate salt 200–600 mg q 6 h to q 12 h, gluconate salt 324–648 mg q 8 h to q 12 h, IV: loading dose: 800 mg in 50 mL infused at 50 mg/min
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[short QT syndrome]], [[brugada]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[Ito]], [[IKr]], M, Alpha receptor
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[QRS prolongation]], [[QTc prolongation]], increased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Syncope]], [[ torsades de pointes]], [[AV]] block, [[dizziness]], [[diarrhea]], [[nausea]], [[esophagitis]], [[emesis]], [[tinnitus]], [[blurred vision]], [[rash]], [[weakness]], [[tremor]], [[blood dyscrasias]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ranolazine]] (not classified), PO: 500–1000 mg q 12 h
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[INa]], [[IKr]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QTc prolongation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[headache]], [[dizziness]], [[syncope]], [[nausea]], [[dyspnea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Sotalol]] (III), IV: 75 mg q 12 h, PO: 80–120 mg q 12 h, may increase dose every 3 d; max 320 mg/d
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[VT]], [[VF]], [[PVC]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[B1]], [[B2]] [[IKr]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]], [[QTc prolongation]], increased [[AV]] nodal refractoriness, decreased [[defibrillation threshold]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[none]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]], [[HF]], [[syncope]], [[TdP]], [[fatigue]], [[dizziness]], [[weakness]], [[dyspnea]], [[bronchitis]], [[depression]], [[nausea]], [[diarrhea]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Verapamil]], IV: 2.5–5 mg q 15–30 min, sustained release PO: 240–480 mg/d
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[RVOT]] [[VT]], [[verapamil]]-sensitive idiopathic [[Left VT]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[ICa-L]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Slowed [[sinus rate]],[[PR]] prolongation, slowed [[AV]] nodal conduction
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metabolism: [[hepatic]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Hypotension]], [[edema]], [[HF]], [[AV]] block, [[bradycardia]], exacerbation of [[HF]] reduced [[EF]], [[headache]], [[rash]], [[gingival hyperplasia]], [[constipation]], [[dyspepsia]]
|}
{{clear}}

==[[Electrolytes]]==
* Correction of [[hypokalemia]] and [[hypomagnesemia]] is helpful for preventing of [[ventricular arrhythmia]] in the setting of [[myocardial infarction]] or [[ diuretic]] therapy in [[heart failure]] [[patients]].<ref name="CooperDries1999">{{cite journal|last1=Cooper|first1=Howard A.|last2=Dries|first2=Daniel L.|last3=Davis|first3=C. E.|last4=Shen|first4=Yuan Li|last5=Domanski|first5=Michael J.|title=Diuretics and Risk of Arrhythmic Death in Patients With Left Ventricular Dysfunction|journal=Circulation|volume=100|issue=12|year=1999|pages=1311–1315|issn=0009-7322|doi=10.1161/01.CIR.100.12.1311}}</ref>
* [[Diuretic therapy]] in [[heart failure]] [[patients]] may lead to [[hypokalemia]] or [[hypomagnesemia]].<ref name="CooperDries1999">{{cite journal|last1=Cooper|first1=Howard A.|last2=Dries|first2=Daniel L.|last3=Davis|first3=C. E.|last4=Shen|first4=Yuan Li|last5=Domanski|first5=Michael J.|title=Diuretics and Risk of Arrhythmic Death in Patients With Left Ventricular Dysfunction|journal=Circulation|volume=100|issue=12|year=1999|pages=1311–1315|issn=0009-7322|doi=10.1161/01.CIR.100.12.1311}}</ref>

* [[Hypokalemia]] and [[hypomagnesemia]] may cause [[ventricular arrhythmia]] during acute [[myocardial infarction]] .
* [[Hypokalemia]] and [[hypomagnesemia]] may increase the risk of [[torsades de pointes]] in patients with use of some [[medications]] with [[QTc prolongation ]] effect or [[long QT syndrome]].<ref name="YanAntzelevitch1998">{{cite journal|last1=Yan|first1=Gan-Xin|last2=Antzelevitch|first2=Charles|title=Cellular Basis for the Normal T Wave and the Electrocardiographic Manifestations of the Long-QT Syndrome|journal=Circulation|volume=98|issue=18|year=1998|pages=1928–1936|issn=0009-7322|doi=10.1161/01.CIR.98.18.1928}}</ref>
* Administration of intravenous [[magnesium]] in the setting of [[torsades de pointes]] as the first line therapy is recommended.<ref name="TzivoniBanai1988">{{cite journal|last1=Tzivoni|first1=D|last2=Banai|first2=S|last3=Schuger|first3=C|last4=Benhorin|first4=J|last5=Keren|first5=A|last6=Gottlieb|first6=S|last7=Stern|first7=S|title=Treatment of torsade de pointes with magnesium sulfate.|journal=Circulation|volume=77|issue=2|year=1988|pages=392–397|issn=0009-7322|doi=10.1161/01.CIR.77.2.392}}</ref>

* [[Potassium]] level should be kept 4.5 mmol/L and 5 mmol/L to prevent [[ventricular arrhythmia]] or [[sudden cardiac death]].<ref name="CohnKowey2000">{{cite journal|last1=Cohn|first1=Jay N.|last2=Kowey|first2=Peter R.|last3=Whelton|first3=Paul K.|last4=Prisant|first4=L. Michael|title=New Guidelines for Potassium Replacement in Clinical Practice|journal=Archives of Internal Medicine|volume=160|issue=16|year=2000|pages=2429|issn=0003-9926|doi=10.1001/archinte.160.16.2429}}</ref>

* In [[patients]] with acute [[MI]] maintaining [[potassium]] level between 3.5 mmol/L and 4.5 mmol/L was associated with lower rate of [[death]] <ref name="GoyalSpertus2012">{{cite journal|last1=Goyal|first1=Abhinav|last2=Spertus|first2=John A.|last3=Gosch|first3=Kensey|last4=Venkitachalam|first4=Lakshmi|last5=Jones|first5=Philip G.|last6=Van den Berghe|first6=Greet|last7=Kosiborod|first7=Mikhail|title=Serum Potassium Levels and Mortality in Acute Myocardial Infarction|journal=JAMA|volume=307|issue=2|year=2012|pages=157|issn=0098-7484|doi=10.1001/jama.2011.1967}}</ref>
*Early administration of intravenous [[magnesium]] in [[patients]] with acute [[STEMI]] has not effect on short term [[mortality]].<ref name="Antman2002">{{cite journal|last1=Antman|first1=Elliott M|title=Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial|journal=The Lancet|volume=360|issue=9341|year=2002|pages=1189–1196|issn=01406736|doi=10.1016/S0140-6736(02)11278-5}}</ref>

==[[Fatty acids]], [[Lipids]]==
* The role of [[N-3 poly-unsaturated fatty acids]] and [[statin]] therapies for preventing of [[SCD]] has been proposed by stabilizing bilipid [[myocyte membrane]] for maintaining [[electrolyte]] gradients. <ref name="LeafKang2003">{{cite journal|last1=Leaf|first1=Alexander|last2=Kang|first2=Jing X.|last3=Xiao|first3=Yong-Fu|last4=Billman|first4=George E.|title=Clinical Prevention of Sudden Cardiac Death by n-3 Polyunsaturated Fatty Acids and Mechanism of Prevention of Arrhythmias by n-3 Fish Oils|journal=Circulation|volume=107|issue=21|year=2003|pages=2646–2652|issn=0009-7322|doi=10.1161/01.CIR.0000069566.78305.33}}</ref>
* Among [[patients]] with recent [[MI]] using [[fish oil]] 1 g/d reduced [[SCD]] and [[mortality]].<ref name="MarchioliBarzi2002">{{cite journal|last1=Marchioli|first1=Roberto|last2=Barzi|first2=Federica|last3=Bomba|first3=Elena|last4=Chieffo|first4=Carmine|last5=Di Gregorio|first5=Domenico|last6=Di Mascio|first6=Rocco|last7=Franzosi|first7=Maria Grazia|last8=Geraci|first8=Enrico|last9=Levantesi|first9=Giacomo|last10=Maggioni|first10=Aldo Pietro|last11=Mantini|first11=Loredana|last12=Marfisi|first12=Rosa Maria|last13=Mastrogiuseppe|first13=G.|last14=Mininni|first14=Nicola|last15=Nicolosi|first15=Gian Luigi|last16=Santini|first16=Massimo|last17=Schweiger|first17=Carlo|last18=Tavazzi|first18=Luigi|last19=Tognoni|first19=Gianni|last20=Tucci|first20=Corrado|last21=Valagussa|first21=Franco|title=Early Protection Against Sudden Death by n-3 Polyunsaturated Fatty Acids After Myocardial Infarction|journal=Circulation|volume=105|issue=16|year=2002|pages=1897–1903|issn=0009-7322|doi=10.1161/01.CIR.0000014682.14181.F2}}</ref>
* Another clinical trial showed using [[n–3 Fatty Acids]] was not effective in the reduction of the [[cardiovascular ]] event in high risk [[patients]].<ref>{{cite journal|title=n–3 Fatty Acids and Cardiovascular Outcomes in Patients with Dysglycemia|journal=New England Journal of Medicine|volume=367|issue=4|year=2012|pages=309–318|issn=0028-4793|doi=10.1056/NEJMoa1203859}}</ref>
* [[Statin]] clearly reduced [[mortality]] and [[SCD]] associated [[ischemic heart disease]].<ref name="LaRosaHe1999">{{cite journal|last1=LaRosa|first1=John C.|last2=He|first2=Jiang|last3=Vupputuri|first3=Suma|title=Effect of Statins on Risk of Coronary Disease|journal=JAMA|volume=282|issue=24|year=1999|pages=2340|issn=0098-7484|doi=10.1001/jama.282.24.2340}}</ref>
* Supressing [[plaque rupture]] or direct [[cardiovascular]] effect are two mechanisms of decrease [[ventricular arrhythmia]] by [[statin]].
* [[Statin]] is effective in prevention of [[ventricular arrhythmia]] in [[ischemic heart disease]], however, the role of [[statine]] in reducing [[SCD]] in [[heart failure]] [[ICD]] [[patients]] is not clearly explained.<ref name="pmid18757089">{{cite journal |vauthors=Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG, Latini R, Lucci D, Nicolosi GL, Porcu M, Tognoni G |title=Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial |journal=Lancet |volume=372 |issue=9645 |pages=1231–9 |date=October 2008 |pmid=18757089 |doi=10.1016/S0140-6736(08)61240-4 |url=}}</ref>

==Specific recommendation==
* The mainstay of therapy in [[heart failure]] reduced [[EF]] for prevention of [[SCD]] and [[ventricular arrhythmia]] is the following:
* [[Beta blocker]]s with benefit for preventing of [[SCD]] by reducing [[sympathetic activity]] and [[ myocardial]] [[oxygen]] demand or countering [[electrical excitability]].
* [[Angiotensin-converting enzyme inhibitors]], or [[angiotensin-receptor blockers]] is effective by reducing [[myocardial oxygen demand]], [[preload]], [[afterload]], prevention the formation of [[angiotensin II]], and slowing the process of [[ventricular remodeling]] and [[fibrosis]].<ref name="pmid2057035">{{cite journal |vauthors=Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong M |title=A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure |journal=N Engl J Med |volume=325 |issue=5 |pages=303–10 |date=August 1991 |pmid=2057035 |doi=10.1056/NEJM199108013250502 |url=}}</ref>
* [[Mineralocorticoid receptor antagonists]] decrease [[potassium loss]], [[decrease fibrosis]], and increase the [[myocardial]] uptake of [[norepinephrine]].
* Chronic [[Beta blocker]]s therapy in [[heart failure]] reduced [[EF]] was associated with reduced [[SCD]], [[ventricular arrhythmia]] and all cause [[mortality]].
*[[Bisoprolol]], [[carvedilol]], [[sustained-release metoprolol succinate]] decrease [[mortality]] in [[patients]] with [[heart failure]] reduced [[EF]].<ref name="pmid10023943">{{cite journal |vauthors= |title=The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial |journal=Lancet |volume=353 |issue=9146 |pages=9–13 |date=January 1999 |pmid=10023943 |doi= |url=}}</ref><ref name="pmid11356434">{{cite journal |vauthors=Dargie HJ |title=Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial |journal=Lancet |volume=357 |issue=9266 |pages=1385–90 |date=May 2001 |pmid=11356434 |doi=10.1016/s0140-6736(00)04560-8 |url=}}</ref><ref name="pmid10714728">{{cite journal |vauthors=Hjalmarson A, Goldstein S, Fagerberg B, Wedel H, Waagstein F, Kjekshus J, Wikstrand J, El Allaf D, Vítovec J, Aldershvile J, Halinen M, Dietz R, Neuhaus KL, Jánosi A, Thorgeirsson G, Dunselman PH, Gullestad L, Kuch J, Herlitz J, Rickenbacher P, Ball S, Gottlieb S, Deedwania P |title=Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group |journal=JAMA |volume=283 |issue=10 |pages=1295–302 |date=March 2000 |pmid=10714728 |doi=10.1001/jama.283.10.1295 |url=}}</ref>
* [[ACEI]] and [[mineralocorticoid-receptor antagonists]] ([[spironolactone]], [[eplerenone]]) reduce [[mortality]] and [[SCD]] in [[patients]] with severe [[heart failure]]. <ref name="pmid10471456">{{cite journal |vauthors=Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J, Wittes J |title=The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators |journal=N Engl J Med |volume=341 |issue=10 |pages=709–17 |date=September 1999 |pmid=10471456 |doi=10.1056/NEJM199909023411001 |url=}}</ref>
==Management of [[patients]] with Polymorphic [[Ventricular arrhythmia]]==
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Polymorphic [[Ventricular arrhythmia]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Underlying etiology]]}}
{{Family tree | |,|-|-|+|-|-|-|v|-|-|-|v|-|-|-|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C0| | C3| | C02 | |C4 | | | | | | | |C5 | | | | | | | | | C3=External precipitating factors| C0=Acute [[ischemia]]| C02= Polymorphic [[Ventricular Arrhythmia]] triggered by unifocal [[PVC]]|C4=[[Acquired long QT]]|C5=Primary [[electrical disease]]}}
{{Family tree |!| | | | | |!| | | |!| | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{Family tree | b1| | b2| |b3 | | |b4 | | | | h1| |h2 | |h3 | | | | |b1= Approach to [[STEMI]] | |b3=
[[Catheter ablation]] (Class IIa)
*[[Quinidine]] (Class IIb)|b4=Remove [[precipitating]] factors (Class I)
*[[Mg]]++/[[K]]+ i.v.(Class I)
*[[Isoproterenol]] (Class I)
*[[Pacing]] (Class I)|h1=[[Brugada]], [[Early repolarization syndrome]]|h2=Idiopathic [[VF]]|h3=[[Long QT]], [[CPVT]]|b2=Treatment of underlying [[condition]] (Class I)}}
{{Family tree | | | | | | |:| | | |:| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | j1| | | |j1 | | j1| | |m1 | |m2 | |m3 | | | | | | | | |j1=[[Recurrent]] [[Ventricular arrhythmia]] | m1=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Catheter ablation]] (Class IIa)|m2=[[Isoproterenol]] (Class IIa)
*[[Quinidine]] (Class IIa)
*[[Verapamil]] (Class IIa
*[[Catheter ablation]] of [[PVC]] triggers (Class IIa)|m3=[[Beta-blocker]] (Class I)
*[[Pacing]] (Class I)
*[[Mg]]++/[[K]]+ i.v (Class I)
*[[Antiarrhythmic]] drugs according to underlying [[disease]] (Class 2a)
*[[Autonomic modulation]] (Class 2a)}}
{{Family tree | | | | | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | |n1 | |n1 | |n1 | | |n2 | |n2 | | n2| | | | | | | | | | | | n1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)|n2= Recurrent [[ventricular arrhythmia]]}}
{{Family tree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | | | | |m1 | |m1 | | m1| | | | | | | | | | | | m1=Deep [[sedation]]/ [[intubation]] (Class IIa)
*[[Mechanical circulatory support]] (Class IIb)}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}
==Management of sustained monomorphic [[ventricular tachycardia]]==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''DC cardiovertion ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[DC cardioversion]] is recommended as the first-line treatment for [[patients]] presenting with tolerated [[sustained monomorphic VT]] when [[anesthetic]]/[[sedation]] risk is low
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] presenting with a regular hemodynamically tolerated wide [[QRS]] complex tachycardia suspected for [[supraventricular tachycardia]], administration of [[adenosine]] or [[vagal maneuvers]] should be considered 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Flecainide, ajmaline, sotalol ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated sustained [[monomorphic VT]] in the absence of significant [[structural heart disease]], [[flecainide]], [[ajmaline]], or [[sotalol]] may be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Verapamil ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}
==Management of electrical storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Strucrural heart disease ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Antiarrhythmic]] therapy with [[beta-blockers]] (non-selective preferred) in combination with intravenous [[amiodarone]] is recommended in [[patients]] with [[structural heart disease]] and [[electrical storm]] unless contraindicated 
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Torsades depointes ([[ESC guidelines classification scheme|Class I, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[magnesium]] with supplementation of [[potassium]] is recommended in [[patients]] with [[TdP]] 
❑[[Isoproterenol]] or [[transvenous pacing]] to increase heart rate is recommended in patients with acquired [[LQT]] syndrome and recurrent [[TdP]] despite correction of precipitating [[conditions]] and [[magnesium]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑Deep [[sedation]]/[[intubation]] should be considered in [[patients]] with an intractable [[electrical storm]] non-responsive [[drug]] treatment 

❑[[Catheter ablation]] should be considered in [[patients]] with recurrent episodes of [[VT]]/[[VF]] triggered by a similar [[PVC]], refractory to medical treatment
or [[coronary revascularization]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Quinidine]] ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Quinidine]] may be considered in [[patients]] with [[coronary artery disease]] and [[electrical storm]] due to recurrent [[VT]] refractory to other [[antiarrhythmic drugs]]
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Refractory electerical storm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Autonomic modulation]] may be considered in [[patients]] with [[electrical storm]] refractory to medical therapy and in whom [[catheter ablation]] is
ineffective or not possible 
❑ [[Mechanical circulatory support]] may be considered in the management of drug-refractory [[electrical storm]] and [[cardiogenic
shock]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== Recommendations for treatment with [[heart failure]] medication ==

{| class="wikitable"
|-
| Colspan="1" style="text-align:center; background:LightGreen"|[[ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| Bgcolor="LightGreen"|<nowiki>"</nowiki>[[Optimal medical treatment]] including [[ACE-I]]/[[ARB]]/ [[ARNIs]], [[mineralocorticoid receptor antagonist]], [[beta-blockers]], and [[SGLT2]] inhibitors is indicated in all [[heart failure]] [[patients]] with reduced [[EF]]''' ([[ESC guidelines classification scheme#Level of Evidence|Level of Evidence A]])<nowiki>"</nowiki>''
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2022 ESC Guideline<ref name="pmid36017572">{{cite journal |vauthors=Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M |title=2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death |journal=Eur Heart J |volume= |issue= |pages= |date=August 2022 |pmid=36017572 |doi=10.1093/eurheartj/ehac262 |url=}}</ref>
|-
|}

== Notes==
* The most common cause of cardiac arrest is [[VF]], [[pulseless VT]], severe [[bradycardia]], and [[asystole]].
* Survival in the presence of [[VF]], [[VT]] is better than [[bradycardia]], [[asystole]] manifestation.<ref name="ZipesCamm2006">{{cite journal|last1=Zipes|first1=Douglas P.|last2=Camm|first2=A. John|last3=Borggrefe|first3=Martin|last4=Buxton|first4=Alfred E.|last5=Chaitman|first5=Bernard|last6=Fromer|first6=Martin|last7=Gregoratos|first7=Gabriel|last8=Klein|first8=George|last9=Moss|first9=Arthur J.|last10=Myerburg|first10=Robert J.|last11=Priori|first11=Silvia G.|last12=Quinones|first12=Miguel A.|last13=Roden|first13=Dan M.|last14=Silka|first14=Michael J.|last15=Tracy|first15=Cynthia|title=ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=114|issue=10|year=2006|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.178233}}</ref>
* Factors associated with better [[survival]] include rapid [[defibrillation]] and initiation of [[CPR ]] for a witnessed [[cardiac arrest]].
* [[Survival]] in [[patients]] with [[cardiac arrest]] decreases rapidly after the initial 2 minutes from the onset of [[cardiac arrest]], by 4 to 5 minutes, survival may be ≤25%, and by 10 minutes it is 0%.<ref name="SassonRogers2010">{{cite journal|last1=Sasson|first1=Comilla|last2=Rogers|first2=Mary A.M.|last3=Dahl|first3=Jason|last4=Kellermann|first4=Arthur L.|title=Predictors of Survival From Out-of-Hospital Cardiac Arrest|journal=Circulation: Cardiovascular Quality and Outcomes|volume=3|issue=1|year=2010|pages=63–81|issn=1941-7713|doi=10.1161/CIRCOUTCOMES.109.889576}}</ref>
* Among [[patients]] with witnessed [[cardiac arrest]] due to initial shock-refractory [[VF]] or pulseless [[VT]], administration of [[amiodarone]] improved survival to hospital discharge compared with placebo in the setting of out-of-hospital [[cardiac arrest]].
* Administration of [[procainamide]] in out-of-hospital cardiac arrest due to [[VF]] or pulseless [[VT]] was correlated with more [[shocks]], more [[pharmacologic]] interventions, longer [[resuscitation]] times, and lower [[survival]].<ref name="Connolly2000">{{cite journal|last1=Connolly|first1=S|title=Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials|journal=European Heart Journal|volume=21|issue=24|year=2000|pages=2071–2078|issn=0195668X|doi=10.1053/euhj.2000.2476}}</ref>
* If left untreated, [[VF]] and pulseless monomorphic or polymorphic [[VT]], causes [[loss of consciousness]] and leads to [[death]].
* A short time to [[direct current cardioversion]] is the major determinant of [[survival]], and [[defibrillation]] should be performed as [[quickly]] as possible.
* [[CPR]] should be continued until restoration a [[perusing]] [[rhythm]].
* If [[defibrillation ]] failed to returning spontaneous [[circulation]], [[advanced cardiovascular life support]] should be followed.
* In unstable [[patients]] suspected [[coronary artery occlusion]] led to [[cardiac arrest]], emergency [[coronary angiography ]] should be considered rather than later in the [[hospital]] regardless the [[patient]] is [[comatose]] or [[awake]].<ref name="SpauldingJoly1997">{{cite journal|last1=Spaulding|first1=Christian M.|last2=Joly|first2=Luc-Marie|last3=Rosenberg|first3=Alain|last4=Monchi|first4=Mehran|last5=Weber|first5=Simon N.|last6=Dhainaut|first6=Jean-François A.|last7=Carli|first7=Pierre|title=Immediate Coronary Angiography in Survivors of Out-of-Hospital Cardiac Arrest|journal=New England Journal of Medicine|volume=336|issue=23|year=1997|pages=1629–1633|issn=0028-4793|doi=10.1056/NEJM199706053362302}}</ref><ref name="ZanuttiniArmellini2012">{{cite journal|last1=Zanuttini|first1=Davide|last2=Armellini|first2=Ilaria|last3=Nucifora|first3=Gaetano|last4=Carchietti|first4=Elio|last5=Trillò|first5=Giulio|last6=Spedicato|first6=Leonardo|last7=Bernardi|first7=Guglielmo|last8=Proclemer|first8=Alessandro|title=Impact of Emergency Coronary Angiography on In-Hospital Outcome of Unconscious Survivors After Out-of-Hospital Cardiac Arrest|journal=The American Journal of Cardiology|volume=110|issue=12|year=2012|pages=1723–1728|issn=00029149|doi=10.1016/j.amjcard.2012.08.006}}</ref>
* [[Coronary]] lesion requiring [[percutaneous coronary intervention]] was found in one-third of [[patients]] with [[out-of-hospital cardiac arrest]] without ST elevation in [[ECG]]. The outcome was reasonable. <ref name="DumasBougouin2016">{{cite journal|last1=Dumas|first1=Florence|last2=Bougouin|first2=Wulfran|last3=Geri|first3=Guillaume|last4=Lamhaut|first4=Lionel|last5=Rosencher|first5=Julien|last6=Pène|first6=Frédéric|last7=Chiche|first7=Jean-Daniel|last8=Varenne|first8=Olivier|last9=Carli|first9=Pierre|last10=Jouven|first10=Xavier|last11=Mira|first11=Jean-Paul|last12=Spaulding|first12=Christian|last13=Cariou|first13=Alain|title=Emergency Percutaneous Coronary Intervention in Post–Cardiac Arrest Patients Without ST-Segment Elevation Pattern|journal=JACC: Cardiovascular Interventions|volume=9|issue=10|year=2016|pages=1011–1018|issn=19368798|doi=10.1016/j.jcin.2016.02.001}}</ref>

* In the presence of incessant [[VT]], [[amiodarone]] was more effective than [[lidocaine]] and improved survival at 24 hours.<ref name="SombergBailin2002">{{cite journal|last1=Somberg|first1=John C|last2=Bailin|first2=Steven J|last3=Haffajee|first3=Charles I|last4=Paladino|first4=Walter P|last5=Kerin|first5=Nicholas Z|last6=Bridges|first6=Duane|last7=Timar|first7=Sandor|last8=Molnar|first8=Janos|title=Intravenous lidocaine versus intravenous amiodarone (in a new aqueous formulation) for incessant ventricular tachycardia|journal=The American Journal of Cardiology|volume=90|issue=8|year=2002|pages=853–859|issn=00029149|doi=10.1016/S0002-9149(02)02707-8}}</ref>

* [[Procainamide]] is superior to [[lidocaine]] in the setting of recurrent stable hemodynamic [[VT]], and also preferred in the absent evidence of acute[[ MI]], or [[Long QTC]] on [[ECG]].<ref name="Gorgelsvan den Dool1996">{{cite journal|last1=Gorgels|first1=Anton P.M.|last2=van den Dool|first2=Adri|last3=Hofs|first3=Anton|last4=Mulleneers|first4=Rob|last5=Smeets|first5=Joep L.R.M.|last6=Vos|first6=Marc A.|last7=Wellens|first7=Hein J.J.|title=Comparison of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia|journal=The American Journal of Cardiology|volume=78|issue=1|year=1996|pages=43–46|issn=00029149|doi=10.1016/S0002-9149(96)00224-X}}</ref>

* [[lidocaine]] was less effective than [[amiodarone]] to improve [[hospital]] admission after [[out-of-hospital cardiac arrest]] due to shock-refractory [[VF]] or polymorphic [[VT]], but there were no differences between the two [[medications]] in [[survival]] to [[hospital]] discharge.
*[[Lidocaine]] improved [[survival]] to [[hospital]] discharge in witnessed [[SCA]] due to initial shock-refractory [[VF]] or pulseless [[VT]].
* Administration of [[beta blocker]] in [[patients]] with recent [[MI]] was associated with reduced [[VF]] and better [[survival]].
* If [[VT]], [[VF]] storm is refractory to [[amiodarone]], [[lidocaine]], or frequent [[cardioversion]], administration of [[betablocker]] has been shown improved [[survival]] and finally reducing [[sympathetic]] tone by [[sedation]] and [[general anesthesia]] are recommended.
* Administration of high-dose [[epinephrine]] ( 0.1 to 0.2 mg/kg IV) in [[out-of-hospital cardiac arrest]] unresponsive to [[defibrillation]], improved survival to [[hospital]] admission, but there was no difference compared to standard-dose [[epinephrine]] in survival to hospital discharge or long term survival compared with standard-dose [[epinephrine]] (1 mg given [[intravenously]] or intraosseously every 3 to 5 minutes).<ref name="pmid1433686">{{cite journal |vauthors=Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J |title=A randomized clinical trial of high-dose epinephrine and norepinephrine vs standard-dose epinephrine in prehospital cardiac arrest |journal=JAMA |volume=268 |issue=19 |pages=2667–72 |date=November 1992 |pmid=1433686 |doi= |url=}}</ref>
* Administration of [[vasopressin]] is no longer recommended in the most recent [[advanced cardiovascular life support]] guideline.<ref name="LinkBerkow2015">{{cite journal|last1=Link|first1=Mark S.|last2=Berkow|first2=Lauren C.|last3=Kudenchuk|first3=Peter J.|last4=Halperin|first4=Henry R.|last5=Hess|first5=Erik P.|last6=Moitra|first6=Vivek K.|last7=Neumar|first7=Robert W.|last8=O’Neil|first8=Brian J.|last9=Paxton|first9=James H.|last10=Silvers|first10=Scott M.|last11=White|first11=Roger D.|last12=Yannopoulos|first12=Demetris|last13=Donnino|first13=Michael W.|title=Part 7: Adult Advanced Cardiovascular Life Support|journal=Circulation|volume=132|issue=18 suppl 2|year=2015|pages=S444–S464|issn=0009-7322|doi=10.1161/CIR.0000000000000261}}</ref>

* Intravenous [[magnesium]] is advised in the presence of [[hypokalemia]] or [[medication]]-induced [[torsades de pointed]] by suppression of early and [[late after depolarization]], and inhibition of [[calcium]] flux into [[cardiomyocytes]].
* Using intravenous [[magnesium]] during in-hospital or [[out-of-hospital cardiac arrest]] or refractory [[VF]] was not associated with restoration of [[circulation]] or [[survival]] benefit.<ref name="Hassan2002">{{cite journal|last1=Hassan|first1=T B|title=A randomised trial to investigate the efficacy of magnesium sulphate for refractory ventricular fibrillation|journal=Emergency Medicine Journal|volume=19|issue=1|year=2002|pages=57–62|issn=14720205|doi=10.1136/emj.19.1.57}}</ref>

* Administration The [[lidocaine]] and [[procainamide]] routinely after [[MI]] for suppression of [[ventricular arrhythmia]] was associated with increased [[mortality]], however,
use of [[beta blockers]] lessened [[mortality]] rate.<ref name="pmid8371471">{{cite journal |vauthors=Teo KK, Yusuf S, Furberg CD |title=Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. An overview of results from randomized controlled trials |journal=JAMA |volume=270 |issue=13 |pages=1589–95 |date=October 1993 |pmid=8371471 |doi= |url=}}</ref>
* Prophylactic use of Higher dose [[amiodarone]] after [[MI]] increase mortality, whereas moderate dose [[amiodarone]] was not superior to placebo.<ref name="Elizari2000">{{cite journal|last1=Elizari|first1=M|title=Morbidity and mortality following early administration of amiodarone in acute myocardial infarction|journal=European Heart Journal|volume=21|issue=3|year=2000|pages=198–205|issn=0195668X|doi=10.1053/euhj.1999.1687}}</ref>

* Every [[wide QRS tachycardia]] in the presence of structural heart disease should be presumed [[VT]] untile proven otherwise such as [[SVT]] with aberrancy.
* Administration of [[verapamil]] in [[wide QRS tachycardia]] may lead to severe [[hypotension]] and [[syncope]] and should be avoided.
* The specific type of [[VT]] is [[verapamil]]-[[sensitive VT]] ([[interfascicular reentry]]) with [[structurally normal heart]], but it is important to notify that the recognition of this [[rhythm]] is difficult at initial presentation.<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>

{{familytree/start| | | | | | | | | | | | | |}}
{{familytree| | | | | | | | | | | A01 | | A01=Sustained monomorphic [[VT]]}}
{{familytree| | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | B01 | | | | | |B01=Hemodynamic stability}}
{{familytree| | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | C01 | | | | | | | | | | | |C02|C01=Stable|C02=Unstable}}
{{familytree| | | | |!| | | | | | | | | | | | | |!| }}
{{familytree| | | | D01 | | | | | | | | | | | |D02|D01=12-Lead [[ECG]], [[history]], [[physical exam]]|D02=[[Dirrect current cardioversion]],[[ACLS]]}}
{{familytree| | | | |!| | | | | | | | | | | | | | | | | | | |}}
{{familytree| | | | E01 |,|-|E00|-|-|-|-|-|-|-|F02| | | | | | E01=Notifying disease causing [[VT]]|E00= Cardioversion(class1) |F02= [[VT]] termination}}
{{familytree| | | | |!| |!| |!| | | | | | | |,|-|^|-|.| | | | | }}
{{familytree| | | | F01 |+|-|F00| | | | | |S02| | S03| | |F01=[[Structural heart disease]]|F00=Intravenous [[ procainamide]] (class2a)|S02=Yes, therapy of underlying [[heart]] disease|S03=NO, [[cardioversion]] (class1)}}
{{familytree| | | | |!| |!| |!| | | | | | | | | | | |!| | | | |}}
{{familytree| | | | L01 |`|-|L00| | | | | | | | | P01 | | | | | L00= Intravenous [[amiodarone]] or [[sotalole]] (class2b)|L01= NO, [[Ideopathic VT]]|P01=[[VT]] termination}}
{{familytree| | | | |!| | | | | | | | | | | | | | |!| | | | | |}}
{{familytree| | | | S01 | | | | | | | | | | | | | |!| | | | | |S01=[[Verapamil]] sensitive [[VT]]: [[Verapamil]] outflow tract [[VT]]: [[betablocker]] (class2a) |}}
{{familytree| | |,|-|^|-|.| | | | | | | | | | |,|-|^|-|.| | | |}}
{{familytree| | |N01| |N02| | | | | | | | | Q01| | Q02| | | | | N01= Effective| N02=Non effective: [[cardioversion]]|Q01= Yes,therapy of underlying heart disease|Q02=NO, [[Sedation]] ,[[anesthesia]], reassessing [[antiarrhythmic]] therapy, repeating [[cardioversion]]}}
{{familytree| | |!| | | | | | | | | | | | | | | | | | |!| | | |}}
{{familytree| | |M01| | | | | | | | | | | | | | | | | R01| | | |M01= Therapy to prevent recurrence of [[VT]] |R01= No [[VT]] termination}}
{{familytree|,|-|^|-|.| | | | | | | | | | | | | | | | |!| | | |}}
{{familytree|!| | | |!| | | | | | | | | | | | | | | | |R02| | |R02= [[Catheter ablation]] (class1) |}}
{{familytree|G01| |G02| | | | | | | | | | | | | | | | | | | | | G01=Catheter ablation (class1)| G02= [[ Verapamil]] , [[betablocker]] (class2a)}}
{{familytree| | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2017 AHA/ACC/HRS Guideline
|-
|}

==Comments==

*Common [[antiarrhythmic]] medications for supression of [[ventricular arrhythmia]] include [[amiodarone]], [[sotalol]], and occasionally [[mexilletine]], [[quinidine]],[[ranolazine]].<ref name="BunchMahapatra2011">{{cite journal|last1=Bunch|first1=T. Jared|last2=Mahapatra|first2=Srijoy|last3=Murdock|first3=David|last4=Molden|first4=Jamie|last5=Weiss|first5=J. Peter|last6=May|first6=Heidi T.|last7=Bair|first7=Tami L.|last8=Mader|first8=Katy M.|last9=Crandall|first9=Brian G.|last10=Day|first10=John D.|last11=Osborn|first11=Jeffrey S.|last12=Muhlestein|first12=Joseph B.|last13=Lappe|first13=Donald L.|last14=Anderson|first14=Jeffrey L.|title=Ranolazine Reduces Ventricular Tachycardia Burden and ICD Shocks in Patients with Drug-Refractory ICD Shocks|journal=Pacing and Clinical Electrophysiology|volume=34|issue=12|year=2011|pages=1600–1606|issn=01478389|doi=10.1111/j.1540-8159.2011.03208.x}}</ref><ref name="KetteringMewis2002">{{cite journal|last1=Kettering|first1=Klaus|last2=Mewis|first2=Christian|last3=Dornberger|first3=Volker|last4=Vonthein|first4=Reinhard|last5=Bosch|first5=Ralph F.|last6=Kuhlkamp|first6=Volker|title=Efficacy of Metoprolol and Sotalol in the Prevention of Recurrences of Sustained Ventricular Tachyarrhythmias in Patients with an Implantable Cardioverter Defibrillator|journal=Pacing and Clinical Electrophysiology|volume=25|issue=11|year=2002|pages=1571–1576|issn=0147-8389|doi=10.1046/j.1460-9592.2002.01571.x}}</ref>
* [[Amiodarone]] is more effective than [[sotalol]] but discontinuation may happen during 12-24 months of use due to adverse effects.<ref name="Connolly2006">{{cite journal|last1=Connolly|first1=Stuart J.|title=Comparison of β-Blockers, Amiodarone Plus β-Blockers, or Sotalol for Prevention of Shocks From Implantable Cardioverter Defibrillators<SUBTITLE>The OPTIC Study: A Randomized Trial</SUBTITLE>|journal=JAMA|volume=295|issue=2|year=2006|pages=165|issn=0098-7484|doi=10.1001/jama.295.2.165}}</ref>
* Contraindication of [[sotalol]] may include severely reduced [[LVEF]] <20% due to its negative inotropic effects and the risk of [[torsades de pointed]].
* In [[patients]] with [[prior]] [[MI]] and recurrent sustained [[monomorphic VT]] despite receiving [[amiodarone]] , [[catheter ablation]] was related to better outcome.<ref name="TungVaseghi2015">{{cite journal|last1=Tung|first1=Roderick|last2=Vaseghi|first2=Marmar|last3=Frankel|first3=David S.|last4=Vergara|first4=Pasquale|last5=Di Biase|first5=Luigi|last6=Nagashima|first6=Koichi|last7=Yu|first7=Ricky|last8=Vangala|first8=Sitaram|last9=Tseng|first9=Chi-Hong|last10=Choi|first10=Eue-Keun|last11=Khurshid|first11=Shaan|last12=Patel|first12=Mehul|last13=Mathuria|first13=Nilesh|last14=Nakahara|first14=Shiro|last15=Tzou|first15=Wendy S.|last16=Sauer|first16=William H.|last17=Vakil|first17=Kairav|last18=Tedrow|first18=Usha|last19=Burkhardt|first19=J. David|last20=Tholakanahalli|first20=Venkatakrishna N.|last21=Saliaris|first21=Anastasios|last22=Dickfeld|first22=Timm|last23=Weiss|first23=J. Peter|last24=Bunch|first24=T. Jared|last25=Reddy|first25=Madhu|last26=Kanmanthareddy|first26=Arun|last27=Callans|first27=David J.|last28=Lakkireddy|first28=Dhanunjaya|last29=Natale|first29=Andrea|last30=Marchlinski|first30=Francis|last31=Stevenson|first31=William G.|last32=Della Bella|first32=Paolo|last33=Shivkumar|first33=Kalyanam|title=Freedom from recurrent ventricular tachycardia after catheter ablation is associated with improved survival in patients with structural heart disease: An International VT Ablation Center Collaborative Group study|journal=Heart Rhythm|volume=12|issue=9|year=2015|pages=1997–2007|issn=15475271|doi=10.1016/j.hrthm.2015.05.036}}</ref>
* Recurrent [[VT]] after [[catheter ablation]] is associated with increased [[mortality]].
* Administration of [[encainide]] or [[flecainide]] for suppression of [[PVC]]s and non sustained [[VT]] in post [[MI]] period was associated with increased [[mortality]] and non fatal [[cardiac arrest]].<ref name="EchtLiebson1991">{{cite journal|last1=Echt|first1=Debra S.|last2=Liebson|first2=Philip R.|last3=Mitchell|first3=L. Brent|last4=Peters|first4=Robert W.|last5=Obias-Manno|first5=Dulce|last6=Barker|first6=Allan H.|last7=Arensberg|first7=Daniel|last8=Baker|first8=Andrea|last9=Friedman|first9=Lawrence|last10=Greene|first10=H. Leon|last11=Huther|first11=Melissa L.|last12=Richardson|first12=David W.|title=Mortality and Morbidity in Patients Receiving Encainide, Flecainide, or Placebo|journal=New England Journal of Medicine|volume=324|issue=12|year=1991|pages=781–788|issn=0028-4793|doi=10.1056/NEJM199103213241201}}</ref>

* In survivors of [[SCA]] use of [[Propafenone]] increased [[mortality]] in comparison with [[beta-blockers]], [[amiodarone]], and the [[ICD]].
* In [[patients]] with prior [[ MI]], Sustained [[monomorphic VT ]] can be due to scar-related reentry, but not acute [[ischemia]].
* [[Antiarrhythmic]] medications or [[ablation]] may be needed to prevent recurrence of [[VT]] in scar-related settings.<ref name="BrugadaAguinaga2001">{{cite journal|last1=Brugada|first1=Josep|last2=Aguinaga|first2=Luis|last3=Mont|first3=Lluı́s|last4=Betriu|first4=Amadeu|last5=Mulet|first5=Jaume|last6=Sanz|first6=Ginés|title=Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction: effects on the electrophysiologic substrate and outcome|journal=Journal of the American College of Cardiology|volume=37|issue=2|year=2001|pages=529–533|issn=07351097|doi=10.1016/S0735-1097(00)01133-5}}</ref>

* Revascularization is recommended in the setting of [[ischemia]] for prevention of [[VF]], [[polymorphic VT]]. <ref name="BerntsenGunnes1993">{{cite journal|last1=Berntsen|first1=R. F.|last2=Gunnes|first2=P.|last3=Lie|first3=M.|last4=Rasmussen|first4=K.|title=Surgical revascularization in the treatment of ventricular tachycardia and fibrillation exposed by exercise-induced ischaemia|journal=European Heart Journal|volume=14|issue=10|year=1993|pages=1297–1303|issn=0195-668X|doi=10.1093/eurheartj/14.10.1297}}</ref>

{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for treatment of recurrent ventricular tachycardia in ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Medications ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[IHD]] and recurrent symptomatic [[ventricular tachycardia]] and frequent [[ICD]] shocks despite programming, [[betablocker]], [[sotalol]], [[amiodarone]] is recommended for supression of [[arrhythmia]] 
❑ In [[patients]] with period [[MI]] and presence of [[VT]] storm refractory to [[amiodarone]] or other [[antiarrhythmic]] drugs, [[catheter ablation ]] is recommended 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Catheter ablation ]] can be the first line therapy for recurrent sustained [[monomorphic VT]] in [[IHD]] 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Class IC [[antiarrhythmic ]] drugs ([[flecainide]], [[propafenone]] ) is harmful for supression of [[ventricular tachycardia]] in [[patients]] with [[perior MI]] 
❑ In [[patients]] with incessant [[VT]]/[[VF]], after controlling [[tachyarrhythmia]] [[ICD]] should be implanted due to avoiding of repeated [[ICD]] [[shocks]] 
❑ In [[patients]] with recurrent [[monomorphic VT]] , only [[revascularization]] is ineffective for preventing of [[tachyarrhythmia]] 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
|-
|}

==Message==

*Although [[ICD]] reduced [[mortality]], painful [[ICD]] shocks can affect on the [[quality of life]] and increases [[morbidity]].
*The frequent of [[ICD]] shocks lessened by [[amiodarone]] plus [[beta blocker]] compared with [[sotalol]] but at the expense of increased risk of [[amiodarone]]-related adverse effects.<ref name="Connolly2006">{{cite journal|last1=Connolly|first1=Stuart J.|title=Comparison of β-Blockers, Amiodarone Plus β-Blockers, or Sotalol for Prevention of Shocks From Implantable Cardioverter Defibrillators<SUBTITLE>The OPTIC Study: A Randomized Trial</SUBTITLE>|journal=JAMA|volume=295|issue=2|year=2006|pages=165|issn=0098-7484|doi=10.1001/jama.295.2.165}}</ref>
* All types of non-ischemic [[cardiomyopathy]] can produce scar-related [[VT]] especially [[cardiac]] [[sarcoidosis]].<ref name="NaruseSekiguchi2014">{{cite journal|last1=Naruse|first1=Yoshihisa|last2=Sekiguchi|first2=Yukio|last3=Nogami|first3=Akihiko|last4=Okada|first4=Hiroyuki|last5=Yamauchi|first5=Yasuteru|last6=Machino|first6=Takeshi|last7=Kuroki|first7=Kenji|last8=Ito|first8=Yoko|last9=Yamasaki|first9=Hiro|last10=Igarashi|first10=Miyako|last11=Tada|first11=Hiroshi|last12=Nitta|first12=Junichi|last13=Xu|first13=Dongzhu|last14=Sato|first14=Akira|last15=Aonuma|first15=Kazutaka|title=Systematic Treatment Approach to Ventricular Tachycardia in Cardiac Sarcoidosis|journal=Circulation: Arrhythmia and Electrophysiology|volume=7|issue=3|year=2014|pages=407–413|issn=1941-3149|doi=10.1161/CIRCEP.113.000734}}</ref>

* [[Catheter ablation]] can be used for treatment of [[scar related]] [[VT]] in [[non-ischemic cardiomyopathy]].<ref name="DinovFiedler2014">{{cite journal|last1=Dinov|first1=Borislav|last2=Fiedler|first2=Lukas|last3=Schönbauer|first3=Robert|last4=Bollmann|first4=Andreas|last5=Rolf|first5=Sascha|last6=Piorkowski|first6=Christopher|last7=Hindricks|first7=Gerhard|last8=Arya|first8=Arash|title=Outcomes in Catheter Ablation of Ventricular Tachycardia in Dilated Nonischemic Cardiomyopathy Compared With Ischemic Cardiomyopathy|journal=Circulation|volume=129|issue=7|year=2014|pages=728–736|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.113.003063}}</ref>
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for treatment of recurrent ventricular tachycardia in non-ischemic heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' Amiodarone, sotalol ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Amiodarone]] or [[sotalol]] is recommended in the presensence of recurrent [[ventricular arrhythmia]] and frequent [[ICD]] shocks despite optimal programming or [[beta blocker]] therapy 
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Catheter ablation]] ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In the setting of frequent [[ventricular arrhythmia]] despite optimal [[ICD]] programming or failed [[antiarrhythmic]] medications, [[catheter ablation]] is recommended 
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2017 AHA/ACC/HRS Guideline<ref name="Al-KhatibStevenson2018">{{cite journal|last1=Al-Khatib|first1=Sana M.|last2=Stevenson|first2=William G.|last3=Ackerman|first3=Michael J.|last4=Bryant|first4=William J.|last5=Callans|first5=David J.|last6=Curtis|first6=Anne B.|last7=Deal|first7=Barbara J.|last8=Dickfeld|first8=Timm|last9=Field|first9=Michael E.|last10=Fonarow|first10=Gregg C.|last11=Gillis|first11=Anne M.|last12=Granger|first12=Christopher B.|last13=Hammill|first13=Stephen C.|last14=Hlatky|first14=Mark A.|last15=Joglar|first15=José A.|last16=Kay|first16=G. Neal|last17=Matlock|first17=Daniel D.|last18=Myerburg|first18=Robert J.|last19=Page|first19=Richard L.|title=2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death|journal=Circulation|volume=138|issue=13|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000549}}</ref>
|-
|}

==References==
{{Reflist|2}}
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[[Category:Up-To-Date cardiology]]
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