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= '''TRICUSPID  ATRESIA''' =
==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<br>
|-
|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]]<br>
❑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>
|-
|}


== '''overview''' ==
==SUDDEN CARDIAC DEATH VICTIM==
Tricuspid atresia is the third  most common cyanotic congenital heart disease in which the non oxygenateD  blood can not flow from  right artrium  to right ventricle due to non development or agenesia of tricuspid valve. Right ventricle is small and pulmonary artery in some cases is stenotic.
{| 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<br>
❑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<br>
❑A comprehensive [[autopsy]] is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of [[age]]<br>
❑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<br>
❑[[Toxicology]] screens are recommended in [[sudden death]] cases with the uncertain cause of [[death]]<br>
❑For [[SCD]] where the cause is known or suspected to be heritable, [[genetic]] testing targeted to the cause is recommended<br>
❑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<br>
❑When an [[autops]]y diagnoses possible heritable [[cardiac]] disease, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment <br>
❑In non-[[autopsied]] cases of [[sudden death]] where inherited [[cardiac]] disease is suspected, it is recommended to refer [[first-degree relatives]] for [[cardiac]] assessment<br>
|-
|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 <br>
|-
|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>
|-
|}


Majority of infants with die in the first year of life without surgery. ASD or PFO are necessary for passing the blood  from right atrium to left system  and with out them the infants will not survive.  
==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]]<br>
|-
|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 <br>
|-
|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<br>
|-
|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<br>
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors<br>
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended<br>
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause<br>
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause<br>
|-
|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>
|-
|}


<br />


== Historical perspective ==
Tricuspid atresia was first discovered by friedrich ludwig  kreysig  in 1817, a German physician who found the obstruction between right atrium and right ventricle in autopsy of cyanotic infants. . The classic term of  tricuspid atresia was used firstly by schuberg in 1861.<br />


== Pathophysiology ==






Inferior vena cava and superior vena cava collect  venous non oxygenate blood  into right atrium. Through ASD  blood reach to left atrium and finally flow into left ventricle  and via aorta artery goes into the rest of body. This blood is the mixture of saturated and unsaturated O2. If there is VSD, this  mixed blood  in left ventricle  come into right ventricle via VSD , then via  pulmonary artery flows into pulmonary bed and becomes  oxygenate ,then returns back into left atrium  . In deminished pulmonary blood flow whether the flow is  dependent on  PDA,  the mixed blood in aora flow from this passage into pulmonary artery and pulmonary bed.In the  presence of  normal positioning of great arteries cyanosis  is more prominent  and  is affected  by the size of VSD .TGA and subaortic stenosis  are others  associated anomalies


== Classification ==
==post cardiac arrest survivors==
Tricuspid atresia is  classified according to connection between ventricles with great arteries(aorta, pulmonary) into two subgroups:(1)  
{| 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]]<br>
|-
|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 <br>
|-
|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<br>
|-
|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<br>
❑Retrieval of recordings from [[CIEDs]] and wearable monitors are recommended for all [[SCA]]
survivors<br>
❑In [[SCA]] survivors, repeated 12-lead [[ECGs]] during stable [[rhythm]] (including high precordial lead [[ECG]), as well as continuous [[cardiac]] monitoring, are recommended<br>
❑[[Coronary]] imaging and [[CMR]] with [[LGE]] are recommended for evaluation of [[cardiac]] structure and function in all [[SCA]] survivors without a clear underlying cause<br>
❑[[Sodium channel blocker]] test and [[exercise testing]] is recommended in [[SCA]] survivors without a clear [[underlying]] cause<br>
|-
|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>
|-
|}


* ·        Normal connection between ventricles and  aorta and pulmonary artery . this type is much more common and consistence 70%-80% of cases.Most patients are cyanotic.
==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<br>
❑[[Catheter ablation]] is recommended in [[patients]] presenting with incessant [[VT]] or [[electrical storm]] due to sustained monomorphic [[VT]] refractory to [[antiarrhythmic]] drugs<br>
|-
|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]]<br>
❑[[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]]<br>
|-
|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<br>


* ·        Aorta comes from small  right ventricle and pulmonary artery comes from left ventricle. Heart failure and pulmonary hypertension are common .  Flow in aorta is dependent on VSD size . Subaortic stenosis and aortic arch anomalies are common
❑[[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]]<br>
|-
|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]]<br>
|-
|}
{|
! 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<br>
|-
|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>
|-
|}


<br />
==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}}


== Differentiating tricuspid atresia  from other Diseases ==
==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]] | | | | | | | | | |}}


* Tricuspid atresia must be differentiated from other diseases that cause  lung  olygemia  and cyanosis , such as


* TS
* PS
* ASD
*TOF


{{Family tree/end}}






== Epidemiology and Demographics ==


* The prevalence of tricuspid atresia  is approximately 1.2 per 100,00  live births(2)


=== Age  ===


* Tricuspid atresia is more commonly observed among infant less than one year old.


=== Gender ===


* Tricuspid atresia affects male and female equally.


=== Race ===


* There is no racial predilection for tricuspid atresia




{| 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]]
|-


<br />
|}
{|
! 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>
|-
|}


== Risk Factors ==


* There is no specific risk factors for occurance of tricuspid atresia during pregnancy .
*Few cases of  VACTERL association and chromosomal abnormalities including triosomy 13,18 and tetrasomy 22 were reported(2)


== Natural History, Complications and Prognosis ==


* Early clinical features  in infants include cyanosis of lips and tongue, difficulty in breathing, tiring easily during feeding.
* severity of cyanosis in infants with pulmonary stenosis  is dependent on the amount of pulmonary blood flow passing through patent dactus arteriosis  .After physiologic clousure  of PDA , the cyanosis will be aggravate.
* In patients with  normal pulmonary blood flow, complications of heart failure occure.
* Prognosis is generally poor with out surgery and majority of patients  will die before 1 year old.  The 15 year survival  of patients with fontan procedure is approximately %92 according to Merry et al.


== Diagnosis ==


=== Diagnostic Criteria ===


* The diagnosis of tricuspid atresia is made when at least  of the following three  diagnostic criteria are met in echocardiography:                         


Absent of color flow doppler in tricuspid valve region


ASD or PFO


Small right ventricle


Left atrium dilation


Left ventricle dilation


== Symptoms ==


* Symptoms of tricuspid atresia in neonates may include the following:


:* Central cyanosis in mucous membranes and tongue
:*Poor feeding and growth retardation
:*Difficulty in breathing
:*Rapid heart beat
:*Rapid breathing


== Physical Examination ==


* Patients with pulmonary stenosis and closed PAD usually appear cyanotic  after birth.
* Physical examination  may be remarkable for:


:* Normal pulses
:* Deminished right ventricle impulse
:* Thrill due to VSD or  severe PS
:*Holosystolic murmure in LSB  due to VSD
:*Continuous murmur of PDA ,occasionally
:*Systolic ejection murmur in left upper sternal border  due to PS
:*clubbing in older patients and unrepaired disease.  <br />
:
:Patients with high pulmonary blood flow without stenosis in pulmonary artery  and with VSD are not cyanotic at birth.
:Physical examination may be remarkable for symptoms and signs  of overt heart failure:
:* Tachypnea
:* poor feeding
:* poor growth
:
:
:


== Laboratory Findings ==


* There are no specific laboratory findings associated with tricuspid atresia


* Polycytemia may be found in cyanotic patients.


== Imaging Findings ==
{| 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]]<br>
❑ Bioprothesis [[AVR]] is recommended when [[anticoagulant]] theray with [[VKA]] is contraindicated, not desired, or can not be managed<br>
|-
|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]]<br>
❑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<br>
❑ For [[patients]] > 65 years of age, [[bioprosthetic]] [[aortic]] [[valve]] is preferred over [[mechanical aortic valve]]<br> 
|-
|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>
|-
|}
<span style="font-size:85%">'''Abbreviations:'''
'''AVR:''' [[Aortic valve replacement]];
'''VKA:''' [[Vitamin K antagonist]]


*
</span>


* Echocardiography  is the imaging modality of choice for tricuspid atresia.Findings include ;ASD, VSD, PDA, and aortic arch anomaly,  left ventricle is larger than right ventricle and color flow doppler is absent between right atrium and right ventricle.
* On EKG, tricuspid atresia is characterized by  left axis deviation, left ventricle hypertrophy, right atrium enlargment  and left atrium enlargment in increment  amount of of pulmonary blood flow.
*CXR may demonestrate situs solitus, left sided aortic arch ,levocardia, absent main pulmonary artery, heart size is dependent on pulmonary blood flow,  occasionally pulmonary oligemia with decrease vascular markings, right aortic arch in %25 of cases.
* Catheterization  may measure  the gradient between left ventricle and left atrium in subaortic stenosis.


== Treatment ==


== Medical Therapy ==


* The mainstay of therapy for cyanotic neonate with severe PS and small VSD  is using  prostaglandin E1 (PGE1) for keeping  patency of ductus arteriosis.
* The mainstay of therapy for heart failure symptoms is using diuretic for reloading and then starting ACEI.


== Surgery ==


* Surgery is the mainstay of therapy for tricuspid atresia.


* ·        In first 8 weeks of life if there is  severe cyanosis  and pulmonary obstruction and  normal positioning aorta and pulmonary artery , making a shunt between systemic  subclavian artery to pulmonary artery  is necessary which is called Blalock -taussig(BT shunt).


* ·        If pulmonary artery comes from left ventricle and is overflowed, PA banding is useful for lowering the pulmonary blood flow.


* ·        In older children, bidirection Glenn shunt which is the connection between superior vena cava to pulmonary artery  will done for transferring the blood to pulmonary system.
*Fontan procedure is  a coduit between inferior vena cava and pulmonary artery and transfers the systemic venous  blood to pulmonary circulation  in age of 2-3 year old.
*Endocarditis prophylaxy before every procedures is recommended.
*


== Prevention ==


* Effective measures for the primary prevention of tricuspid atresia include fetal echocardiography and sonography in 20th weeks of pregnancy for prenatal screening.


* Once diagnosed and surgically treated ,post operated  patients with  fontan  palliative shunt should be evaluated by cardiac MRI. follow up may be about the complications of fontal shunt including:(3)


Exercise intolerance as the result of ventricular failure,


Pericardial and pleural effusion,chylothorax and protein losing enteropathy due to lymphatic dysfunction


Pulmonary emboli,blood clot formation in shunt


Liver failure and portal hypertention as a result of increased pressure in shunt.                     


leakage of anastomosis and pulmonary hypertention.


Right atrium dilation and arrhythmia
{| 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'''


== References ==
|-
|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<br>
❑Either [[SAVR]] or transfemoral [[TAVI]] is recommended in [[symptomatic]] severe [[AS]] who are 65-80 years after evaluation about [[life expectancy]] and [[valve]] durability<br>
❑[[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]]<br>
❑ [[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]]<br>
|-
|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]]<br>
❑ 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]]<br>


:<nowiki>1..{cite book | last = Zipes | first = Douglas | title = Braunwald's heart disease : a textbook of cardiovascular medicine | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2019 | isbn = 978-0323462990 }}</nowiki>
|-
:*
|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<br>
|-
|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]]<br>
|
|}
{|
! 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>
|-
|}


2.Minocha PK, Phoon C. Tricuspid Atresia. [Updated 2020 Jan 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.  Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK554495/</nowiki>


3.Fredenburg TB, Johnson TR, Cohen MD. The Fontan procedure: anatomy, complications, and manifestations of failure. ''Radiographics''. 2011;31(2):453-463. doi:10.1148/rg.312105027
<span style="font-size:85%">'''Abbreviations:'''
'''SAVR:''' [[ Surgical aortic valve replacement]];
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
'''AS:''' [[Aortic stenosis]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
</span>
<br>


<br />
*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]]<br>❑VC>0.6cm<br>❑ [[Holodiastolic aortic flow reversal]]<br>❑ RVol≥60 ml<br>❑ RF≥ 50%<br>❑ [[ERO]]≥0.3cm²|B04=Other [[cardiac]] [[surgery]]}}
{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | | | |!| | |}}
{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | | | C04 |C01= Symptomatic  (stage D)<br> | C02=Asymptomatic (stage C) <br>|C04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])  }}
{{Family tree | |!| | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | }}
{{Family tree | |!| | | D01 | | | | | | D03 | | D04 | | D05 | | | | | | | | D01= ❑ [[LVEF]]≤ 55% (stage C2) <br> |D03=❑ Other [[cardiac surgery]]surgery| D04= ❑ [[LVEF]]> 55% <br>AND <br> ❑ [[LVESD]] > 50mm ([[LVESD]]>25mm/m² <br>)| 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}}
<span style="font-size:85%">'''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]]</span>
{|
! 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}}
<span style="font-size:85%">'''Abbreviations:'''
'''TR:''' [[Tricuspid Regurgitation]];
'''TV:''' [[Tricuspid valve]];
'''RV:''' [[Right ventricle]] 
</span>
<br>
 
{|
! 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  <br>
|-
|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]]<br>
|-
|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]]<br>
|-
|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 <br>
|-
|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<br>
|-
|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]]<br>
|-
|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]]<br>
|-
|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]]<br>
|-
|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]])<br>
|-
|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]]<br>
|-
|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]]<br>
|-
|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<br>
 
|}
{|
! 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>
|-
|}
 
 
<span style="font-size:85%">'''Abbreviations:'''
'''[[UFH]]:''' [[Unfractionated heparin]];
'''VKA:''' [[ Vitamin K antagonist]]
</span>
<br>
 
===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>
|-
|}
 
 
<span style="font-size:85%">'''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]]
</span>
<br>
 
 
 
 
 
 
 
 
===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<br>
❑Bridging of [[OAC]] is recommended in [[patients]] with any of the following:
* [[Mechanical prosthetic]] [[heart]] [[valve]]<br>
* [[AF]] with significant [[mitral stenosis]]<br>
* [[AF]] with a [[CHA2DS2-VASc]] score ≥ 3 for [[women]] or 2 for [[men]]<br>
* Acute [[thrombotic]] event within the previous 4 weeks<br>
*High acute [[thrombotic]] risk<br>
❑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]]<br>
❑ Maintaning [[aspirin]] therapy , if indicated, is recommended in [[patients]] undergoing [[surgery]] during the [[periprocedural]] period<br>
❑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<br>
|-
|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  <br>
|-
|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]]<br>
|-
|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]]<br>
|-
|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<br> 
❑ In [[patients]] treated with an [[OAC]], discontinuation of [[antiplatelet]] treatment is recommended after 12 months<br>
|-
|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)<br>
|-
|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]]<br>
❑In [[patients]] requiring [[aspirin]] and/or [[clopidogrel]] in addition to [[VKA]], target [[INR]] should be considered in the lower part of the recommended target<br>
|-
|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<br>
❑ For [[patients]] with [[biological heart valve]], [[OAC]] is recommended if they have other indications for [[anticoagulation]]<br>
|-
|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 <br>
❑ 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 <br>
❑ 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<br>
|-
|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]]<br>
❑[[NOACs]] may be considered over [[VKA]] within 3 months following [[surgical]] implantation of a [[biological heart valve]] in [[mitral]] position in [[patients]] with [[AF]]<br>
|-
|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]]<br>
|-
|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<br>
|-
|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]]<br>
❑[[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 <br>
|-
|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]]<br>
|-
|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>
|-
|}
 
 
<span style="font-size:85%">'''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]]
</span>
<br>
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
===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]]<br>
❑A [[mechanical prosthesis]] is recommended in [[patients]] at risk of [[structural valve deterioration]]<br>
|-
|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<br>
❑A [[mechanical prosthesis]] should be considered in [[patients]] with a reasonable life expectancy and high risk for redo [[valve surgery]] or [[TAVI]] <br>
|-
|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<br>
|-
|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]]<br>
|-
|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]]<br>
❑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]]<br>
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]]<br><br>
|-
|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<br>
❑A [[bioprosthesis]] should be considered in young [[women]] in the age of [[pregnancy]]<br>
❑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<br>
|-
|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]]<br>
|
|}
{|
! 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>
|-
|}
 
 
<span style="font-size:85%">'''Abbreviations:'''
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
'''AF:''' [[Atrial fibrillation]];
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
 
</span>
<br>
 
===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]]<br>
❑ [[Surgery]] is recommended in patients with severe [[tricuspid stenosis]] undergoing left-sided [[valve]] [[intervention]]<br>
|-
|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<br>
❑[[Surgery]] is recommended in [[symptomatic]] [[patients]] with isolated severe primary [[tricuspid regurgitation]] without severe [[RV dysfunction]]<br>
 
|-
|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]]<br>
❑[[Surgery]] should be considered in asymptomatic or mildly symptomatic [[patients]] with isolated severe primary [[tricuspid regurgitation]] and [[RV dilatation]] who are appropriate for [[surgery]]<br>
|-
|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<br>
|-
|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]]<br>
❑[[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]]<br>
|-
|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]]<br>
 
|
|}
{|
! 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}}
 
<span style="font-size:85%">'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''MVA:'''[[Mitral valve area]]
</span>
<br>
 
{{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]]<br>
|-
|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]]<br>
 
|-
|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]] <br>
❑[[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]])<br>
|
|}
{|
! 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>
|-
|}
 
 
<span style="font-size:85%">'''Abbreviations:'''
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]];
'''AF:''' [[Atrial fibrillation]];
'''LA:''' [[Left atrium]];
'''MVA:'''[[Mitral valve area]] ;
</span>
<br>
 
*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>
|-
|}
 
 
<span style="font-size:85%">'''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]]
</span>
<br>
 
 
 
 
 
 
 
 
 
===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]]<br>
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]]<br>
|-
|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]]<br>
 
|-
|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<br>
|-
|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]]<br>
❑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<br>
|
|}
{|
! 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>
|-
|}
 
 
<span style="font-size:85%">'''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]]
</span>
<br>
 
 
 
 
 
 
 
 
 
 
 
 
===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}}
 
<span style="font-size:85%">'''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]];
 
</span>
<br>
 
{|
! 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<br>
❑ [[Surgery]] is recommended in  low risk symptomatic [[patients]] <br>
❑ [[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]])<br>
❑[[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)<br>
|-
|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<br>
|
|}
<span style="font-size:85%">'''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]];
 
</span>
<br>
 
{|
! 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)<br>
❑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<br>
|-
|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 ]] <br>
❑ [[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<br>
|-
|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<br>
|-
|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 <br>
|-
|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<br>
|-
|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<br>
* Severe [[valve]] [[calcification]] ( assessed by [[CCT]]) and [[Vmax]] progression ≥0.3 m/s/year<br>
* Elevated [[BNP]] levels (>3× [[age]]- and [[sex]]-corrected normal range) confirmed by repeated measurements and without other causes<br>
|-
|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<br>
|-
|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]]<br>
❑[[SAVR]] or [[TAVI]] are recommended for [[patients]] based on [[clinical]], [[anatomical]], and [[procedural]] [[characteristics]]<br>
|-
|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]]<br>
|}
<span style="font-size:85%">'''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]]
 
</span>
<br>
 
{|
! 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;" | +
|}
<span style="font-size:85%">'''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]]
 
 
</span>
<br>
 
{|
! 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}}
<span style="font-size:85%">'''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]]
 
 
</span>
<br>
 
{|
! 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}}
</span>
<br>
 
{|
! 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<br>
❑ [[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]]<br>
❑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<br>
|-
|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<br>
|-
|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]])<br>
<span style="font-size:85%;color:red">Risk factors<span style="color:red">:</span> family history of aortic dissection (or personal history of spontaneous vascular dissection),<span style="color:red"> </span> severe aortic or mitral regurgitation, <span style="color:red"></span> <span style="color:red"> desire for pregnancy</span>, <span style="color:red">uncontrolled systemic arterial hypertension </span>, <span style="color:red">aortic size increase >3 mm/year </span>
* >_50 mm in the presence of a [[bicuspid valve]] with additional risk factorsd or [[coarctation]]<br>
❑ 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<br>
|}
<span style="font-size:85%">'''Abbreviations:'''
'''BSA:''' [[Body surface area]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''LV:''' [[Left ventricle]];
'''LVEF:'''[[Left ventricular ejection fraction]] ;
'''LVESV:'''[[Left ventricular end-systolic diamete]]
 
 
</span>
<br>
 
{|
! 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]]<br>
.
|-
|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]]<br>
|}
<span style="font-size:85%">'''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]]
 
</span>
<br>
 
{|
! 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]]<br>
* Suspected [[myocardial ischemia]]<br>
* [[Left ventricular]] [[systolic dysfunction]]<br>
* In men >40 years of age and [[postmenopausal]] [[women]]<br>
* One or more [[cardiovascular]] [[risk factors]]<br>
* Evaluation of severe [[mitral regurgitation]] <br>
|-
|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]]<br>
|-
|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%<br>
|-
|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% <br>
|-
|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<br>
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments<br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]
 
</span>
<br>
 
{|
! 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]]<br>
|-
|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]] <br>
|-
|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 <br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]] 
</span>
<br>
 
{|
! 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]]<br>
|-
|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]] <br>
|-
|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 <br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''NOAC:''' [[Novel oral anticoagulant]];
'''VKA:''' [[Vitamin-K antagonist]];
'''AF:''' [[Artial fibrillation]] 
</span>
<br>
 
{|
! 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<br>
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]]<br>
|-
|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]]<br>
|-
|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<br>
|-
|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 <br>
|-
|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<br>
|-
|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<br>
|-
|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]]<br>
|-
|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<br>
|-
|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]]<br>
|-
|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]]<br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]]  ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];
</span>
<br>
 
{|
! 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

Latest revision as of 09:30, 16 September 2022

secondary prevention of sudden cardiac death

SUDDEN CARDIAC DEATH VICTIM

Recommendations for secondary prevention of sudden cardiac death
ICD implantation (Class I, Level of Evidence A):

ICD implantation is recommended in patients with documented VF or hemodynamically not-tolerated VT in the absence of reversible causes

Amiodarone, Catheter ablation (Class IIb, Level of Evidence C) :

❑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

The above table adopted from 2022 ESC Guideline[1]

SUDDEN CARDIAC DEATH VICTIM

Recommendations for evaluation of sudden cardiac arrest victims
Medical history, Autopsy, Toxicology, Genetic testing (Class I, Level of Evidence B):

❑ 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 autopsy 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

(Class IIb, Level of Evidence C) :

❑Following sudden arrhythmic death syndrome, post-mortem genetic testing in the decedent for additional genes may be considered

(Class III, Level of Evidence B)

❑Following sudden arrhythmia death syndrome, hypothesis-free post-mortem genetic testing using exome or genome sequencing is not recommended

The above table adopted from 2022 ESC Guideline[1]

post cardiac arrest survivors

Recommendations for evaluation of sudden cardiac arrest survivors
Extra cardiac cause (Class I, Level of Evidence B):

❑ The investigation of a SCA survivor without obvious extra-cardiac cause is recommended by a multidisciplinary team

Coronary angiogram (Class I, Level of Evidence C) :

❑ In electrically unstable patients after SCA, with suspicion of ongoing myocardial ischemia, a coronary angiogram is indicated

Brain and chect CT scan (Class I, Level of Evidence C)

❑In SCA survivors, brain/chest CT scan should be considered when patient characteristics, ECG, and echocardiography are not consistent with a cardiac cause

Blood sample, ECG, Cardiac imaging (Class I, Level of Evidence B)

❑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

Echocardiography (Class IC, Level of Evidence B)

Echocardiography is recommended to evaluate cardiac structure and function in all SCA survivors

Coronary vasospasm (Class IIb, Level of Evidence B)

❑In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be considered for the diagnosis of coronary vasospasm

The above table adopted from 2022 ESC Guideline[1]




post cardiac arrest survivors

Recommendations for evaluation of sudden cardiac arrest survivors
Extra cardiac cause (Class I, Level of Evidence B):

❑ The investigation of a SCA survivor without obvious extra-cardiac cause is recommended by a multidisciplinary team

Coronary angiogram (Class I, Level of Evidence C) :

❑ In electrically unstable patients after SCA, with suspicion of ongoing myocardial ischemia, a coronary angiogram is indicated

Brain and chect CT scan (Class I, Level of Evidence C)

❑In SCA survivors, brain/chest CT scan should be considered when patient characteristics, ECG, and echocardiography are not consistent with a cardiac cause

Blood sample, ECG, Cardiac imaging (Class I, Level of Evidence B)

❑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

Echocardiography (Class IC, Level of Evidence B)

Echocardiography is recommended to evaluate cardiac structure and function in all SCA survivors

Coronary vasospasm (Class IIb, Level of Evidence B)

❑In SCA survivors, ergonovine, acetylcholine, or hyperventilation testing may be considered for the diagnosis of coronary vasospasm

The above table adopted from 2022 ESC Guideline[1]

vt storm

Recommendations for management of electrical storm
Sedation (Class I, Level of Evidence C):

❑ Mild to moderate sedation is recommended in patients with the electrical storm to reduce psychological distress and reduce sympathetic tone

Strucrural heart disease (Class I, Level of Evidence B) :

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

Torsades depointes (Class I, Level of Evidence C)

❑ 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

Procainamide (Class IIa, Level of Evidence B)

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT and presence of structural heart disease, intravenous procainamide should be considered

Intubation (Class IIa, Level of Evidence C)

❑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

Quinidine (Class IIb, Level of Evidence C)

Quinidine may be considered in patients with coronary artery disease and electrical storm due to recurrent VT refractory to other antiarrhythmic drugs

The above table adopted from 2022 ESC Guideline[1]

vt

Recommendations for acute management of sustained VT
DC cardiovertion (Class I, Level of Evidence B):

DC cardioversion is recommended as the first-line therapy for hemodynamically not-tolerated sustained monomorphic ventricular tachycardia

DC cardiovertion (Class I, Level of Evidence C) :

DC cardioversion is recommended as the first-line treatment for patients presenting with tolerated sustained monomorphic VT when anesthetic/sedation risk is low

Supraventricular tachycardia (Class IIa, Level of Evidence C)

❑ 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

Procainamide (Class IIa, Level of Evidence B)

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT and presence of structural heart disease, intravenous procainamide should be considered

Flecainide, ajmaline, sotalol (Class IIb, Level of Evidence B)

❑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

Verapamil (Class III, Level of Evidence B)

❑Intravenous verapamil is not recommended in wide QRS complex tachycardia of unknown mechanism

The above table adopted from 2022 ESC Guideline[1]

polymorphic vt

 
 
 
Polymorphic Ventricular arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Underlying etiology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute ischemia
 
External precipitating factors
 
Polymorphic Ventricular Arrhythmia triggered by unifocal PVC
 
Acquired long QT
 
 
 
 
 
 
 
Primary electrical disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approach to STEMI
 
Treatment of underlying condition (Class I)
 
Catheter ablation (Class IIa)
 
 
Remove precipitating factors (Class I)
  • Mg++/K+ i.v.(Class I)
  • Isoproterenol (Class I)
  • Pacing (Class I)
  •  
     
     
    Brugada, Early repolarization syndrome
     
    Idiopathic VF
     
    Long QT, CPVT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Recurrent Ventricular arrhythmia
     
     
     
    Recurrent Ventricular arrhythmia
     
    Recurrent Ventricular arrhythmia
     
     
    Isoproterenol (Class IIa)
     
    Isoproterenol (Class IIa)
  • Quinidine (Class IIa)
  • Verapamil (Class IIa
  • Catheter ablation of PVC triggers (Class IIa)
  •  
    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)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Deep sedation/ intubation (Class IIa)
     
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
     
    Recurrent ventricular arrhythmia
     
    Recurrent ventricular arrhythmia
     
    Recurrent ventricular arrhythmia
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Deep sedation/ intubation (Class IIa)
     
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    The above algorithm adopted from 2022 ESC Guideline[1]

    AS

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    V1
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    _
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    +
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Positive inferior leads
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Positive inferior leads
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    0
     
    1,2
     
    3
     
     
     
     
     
     
     
    3
     
    1,2
     
    0
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    V3
     
    V3
     
    V3
     
     
     
     
     
     
    Left lateral
     
     
    Left posterolateral
     
    V1/1 ratio
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    _
     
    +
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Right posterior
     
    Right paraseptal
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    <1
     
    ≥1
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    _
     
     
    +
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Lead 2, Notched QS
     
     
    Left posterolateral
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Right lateral
     
    Nodo-Hisian
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    _
     
     
    +
     
     
     
     
     
     
     
     
     
    Deep coronary sinus
     
    Left paraseptal
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Nodo-Hisian
     
     
    Right atrium
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    a1


     
     
     
     
     
    Orthodromic AVRT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Pre-excitation on resting ECG
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Ablation candidate, willing to undergo ablation
     
     
     
     
     
     
     
     
     
    Ablation candidate, patient prefers ablation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    N0
     
     
     
    Yes
     
     
    Yes
     
     
     
     
     
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Flecainide or propafenone in the absent of structural heart disease (class 2a)
     
    Amiodarone, betablocker, diltiazem, dofetilide, sotalol, verapamil (class 2b)
     
     
    Catheter ablation (class 1)
     
    Catheter ablation (class 1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Betablocker, diltiazem, verapamil (class1)
     
     
    Flecainide, propafenone in the absent of structural heart disease (class 2a)
     
    Amiodarone, digoxin, dofetilide, sotalol (class 2b)
     
     
     
     
     
     
     
     
     
    If ineffective, consider ablation
     
    If ineffective, consider ablation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    If ineffective, consider ablation
     
    If ineffective, consider ablation
     
    If ineffective, consider ablation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     







    Characteristics Favors SAVR Favors TAVI Favors palliation
    Age/life expectancy Younger age/longer life expectancy Older age/fewer expected remaining years of life Limited life expectancy
    Valve anatomy Calcific AS of a trileaflet valve
    Prosthetic valve preference
    Concurrent cardiac conditions Severe calcification of the ascending aorta (porcelain aorta)
    Noncardiac conditions
    Frailty Not frail or few frailty measures Frailty likely to improve after TAVI Severe frailty unlikely to improve after TAVI
    Estimated procedural or surgical risk of SAVR or TAVI
    • TAVI risk low to medium
    • SAVR risk high to prohibitive
    Prohibitive SAVR risk (>15%) or post-TAVI life expectancy <1 y
    Procedural specific impediments
    Goals of Care and patient preferences and values
    The above table adopted from 2020 AHA Guideline[2]












    Recommendations for choice of Mechanical Versus Bioprosthetic AVR
    (Class I, Level of Evidence C):

    ❑ 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

    (Class IIa, Level of Evidence B):

    ❑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

    (Class IIb, Level of Evidence B):

    ❑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

    The above table adopted from 2020 AHA Guideline[2]

    Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist










    Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate
    (Class I, Level of Evidence A):

    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

    (Class I, Level of Evidence B):

    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

    (Class I, Level of Evidence C):

    ❑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

    (Class IIb, Level of Evidence C):

    ❑For critically ill patients with severe AS, percutaneous aortic ballon dilation is a bridge to TAVI or SAVR

    The above table adopted from 2020 AHA Guideline[2]


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







    b1

    Class Level Recommendations
    I C Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
    IIa B-NR Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
    IIa 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

     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Aortic Regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Moderate Aortic Regurgitation>
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe Aortic Regurgitation
    ❑VC>0.6cm
    Holodiastolic aortic flow reversal
    ❑ RVol≥60 ml
    ❑ RF≥ 50%
    ERO≥0.3cm²
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Other cardiac surgery
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptomatic (stage D)
     
     
     
     
     
     
     
     
     
    Asymptomatic (stage C)
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class IIa)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    LVEF≤ 55% (stage C2)
     
     
     
     
     
    ❑ Other cardiac surgerysurgery
     
    LVEF> 55%
    AND
    LVESD > 50mm (LVESD>25mm/m²
    )
     
    ❑ Progressive decrese in LVEF to <55%-60% or increase in LVEDD to >65mm on at least 3 studies
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class I)
     
    AVR (Class I)
     
     
     
     
     
    AVR (Class I)
     
    AVR (Class IIa)
     
    Low surgical risk
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVR (Class IIb)
     

    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

    The above algorithm adopted from 2020 AHA Guideline[2]

    a1

     
     
     
     
     
     
     
     
    Tricuspid regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Progressive TR (Stage B)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    At time of left sided valve surgery
     
     
     
     
     
     
     
     
     
     
     
    Severe TR (Stage C,D)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Annular dilation> 4 cm, or perior righ heart failure
     
     
     
     
     
     
     
    Asymptomatic (Stage C)
     
    At time of left sided valve surgery
     
     
    Right heart failure (Stage D)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TV surgery (2a)
     
     
     
     
     
     
     
     
    Primary TR with progressive RV dilation or systolic dysfunction
     
    TV surgery (1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TV surgery (2b)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Primary TR
     
     
    Prior left sided valve surgery
     
    Secondary TR
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TV surgery (2a)
     
     
    Absent of severe pulmonary hypertension or RV systolic dysfunction
     
    Poor response to medical therapy
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TV surgery (2b)
     
     
    Annular dilation without pulmonary hypertension or left sided disease
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TV surgery (2a)
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: TR: Tricuspid Regurgitation; TV: Tricuspid valve; RV: Right ventricle

    The above algorithm adapted from 2020 AHA Guideline[2]

    A

    Recommendations for management of prosthetic valve dysfunction
    Mechanical prosthetic thrombosis (Class I, Level of Evidence B):

    ❑ In patients with obstructive thrombosis who are critically ill patients without serious comorbidities, urgent or emergency valve replacement is recommended

    (Class IIa, Level of Evidence B):

    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

    (Class IIa, Level of Evidence C):

    Surgery should be considered for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism

    Bioprosthetic thrombosis (Class I, Level of Evidence C):

    ❑ In bioprosthetic valve thrombosis, anticoagulation using a VKA and/or UFH is recommended before considering re-intervention

    (Class IIa, Level of Evidence B):

    Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion causing elevated gradients, at least until resolution

    Hemolysis and paravalvular leak (Class I, Level of Evidence C):

    ❑ Reoperation is considered when a paravalvular leak is related to endocarditis or leading haemolysis requiring repeated blood transfusions or causes severe heart failure symptoms

    (Class IIa, Level of Evidence B):

    Transcatheter closure is recommended for suitable paravalvular leaks with clinically significant regurgitation and/or haemolysis in high risk patients for surgery

    (Class IIa, Level of Evidence C):

    Transcatheter or surgical closure of clinically significant paravalvular leaks is considered based on patient risk status, leak morphology, and local expertise

    Bioprosthetic failure (Class I, Level of Evidence C):

    ❑Reoperation is recommended in symptomatic patients with severe regurgitation or a significant increase in transprosthetic gradient (after exclusion of valve thrombosis)

    (Class IIa, Level of Evidence B):

    ❑ 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

    (Class IIb, Level of Evidence B):

    Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in high risk patients for surgery

    (Class IIa, Level of Evidence C):

    ❑Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if reoperation is low risk

    The above table adopted from 2021 ESC Guideline[3]


    Abbreviations: UFH: Unfractionated heparin; VKA: Vitamin K antagonist

    B

     
     
     
    Antithrombotic therapy for valve prostheses
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Mechanical heart valve
     
     
     
    Bioprosthetic heart valve
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    VKA lifelong (Class I)
     
    MVR/TVR
     
    SAVR
     
    TAVI
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    CAD
     
     
    Other indications for oral anticoagulation
     
    Other indications for oral anticoagulation
     
    Other indications for oral anticoagulation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Add low-dose ASA in low risk patients for bleeding (Class IIb)
     
    NO
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Subtherapeutic INR for major planned invasive procedure
     
    OAC for 3 months (Class IIa)
     
    OAC long-term (Class I)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Bridging anticoagulation with UFH or LMWH (not required for minor surgeries) (Class I)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    SAPT or OAC for 3 months (Class IIa)
     
     
    OAC long-term (Class I)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    SAPT long-term (Class I)
     
     
    OAC long-term (Class I)
     
     
     
    The above algorithm adopted from 2021 ESC Guideline[3]


    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

    Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods
    Management of antithrombotic therapy in the perioperative period (Class I, Level of Evidence C):

    ❑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:

    ❑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

    (Class I, Level of Evidence B):

    ❑For bridging, therapeutic doses of either UFH or subcutaneous LMWH are recommended

    (Class I, Level of Evidence C):

    ❑ Re-initiation of the VKA on the first postoperative day is recommended in patients with mechanical valve

    (Class IIb, Level of Evidence C):

    ❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism

    Concomitant antiplatelet therapy (Class I, Level of Evidence B):

    ❑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

    (Class IIa, Level of Evidence C):

    ❑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)

    (Class IIa, Level of Evidence B):

    ❑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

    Surgical valve replacement (Class I, Level of Evidence B):

    ❑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

    (Class IIa, Level of Evidence B):

    ❑ 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

    (Class IIb, Level of Evidence C):

    ❑ 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

    (Class IIa, Level of Evidence C):

    ❑ Low-dose aspirin (75-100 mg/day) in addition to VKA should be considered after thromboembolism despite an adequate INR

    (Class III, Level of Evidence B):

    NOACs are not recommended in patients with a mechanical valve prosthesis

    Surgical valve repair (Class IIa, Level of Evidence C):

    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

    Transcatheter aortic valve replacement (Class I, Level of Evidence B):

    OAC is recommended lifelong for TAVI patients who have other indications for OAC

    (Class I, Level of Evidence A):

    ❑Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC

    (Class III, Level of Evidence B):

    ❑ Routine use OAC is not recommended after TAVI in patients with no baseline indication for OAC

    The above table adopted from 2021 ESC Guideline[3]


    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

    Recommendations for prosthetiv valve disease
    Mechanical protheses (Class I, Level of Evidence C):

    ❑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

    (Class IIa, Level of Evidence C):

    ❑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

    (Class IIa, Level of Evidence B):

    ❑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

    (Class IIb, Level of Evidence C):

    ❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism

    Biological prothesis (Class I, Level of Evidence C):

    ❑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

    (Class IIa, Level of Evidence C):

    ❑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

    (Class IIb, Level of Evidence B):

    ❑A bioprosthesis may be considered in patients already on long-term NOACs for whom are high risk for thromboembolism

    The above table adopted from 2021 ESC Guideline[3]


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


    G

    Recommendations for intervention in tricuspid valve disease
    Tricuspid stenosis (Class I, Level of Evidence C):

    Surgery is recommended in symptomatic patients with severe tricuspid stenosis
    Surgery is recommended in patients with severe tricuspid stenosis undergoing left-sided valve intervention

    Primary Tricuspid Regurgitation (Class I, Level of Evidence C):

    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

    Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):

    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

    Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):

    Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery

    Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):

    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

    Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):

    Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients

    The above table adopted from 2021 ESC Guideline[3]








    =F

     
     
     
    Management of clinically significant rheumatic mitral stenosis (MVA ≤ 1.5 cm2)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptoms
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    High risk of embolism or hemodynamic decompensation
     
     
     
     
    Contraindication to PMC
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
    NO
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    PMC if favourable characteristics for PMC or contraindication for surgery
     
    Exercise test
     
     
    Contraindication or high risk for surgery
     
     
    Surgery
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptoms
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
     
     
    PMC
     
     
    Favourable anatomical characteristics
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Follow-up
     
    Contraindication to or unfavourable characteristics for PMC
     
     
     
     
     
     
    NO
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
     
     
     
     
    Surgery
     
     
    PMC
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    PMC
     
    Surgery
     
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: PMC: Percutaneous mitral commissurotomy; MVA:Mitral valve area

    The above algorithm adopted from 2021 ESC Guideline[3]








    K

    Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)
    (Class I, Level of Evidence B):

    PMC is recommended in symptomatic patients with favourable characteristics for PMC

    (Class I, Level of Evidence C):

    PMC is recommended in any symptomatic patients who are high risk for surgeryMitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility

    (Class IIa, Level of Evidence C):

    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:

    The above table adopted from 2021 ESC Guideline[3]


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






    P

     
     
     
    Management of patients with chronic severe secondary mitral regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptomatic despite medical therapy
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    *Optimazing medical therapy
    • CRT implantation if indicated
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe comorbidities or life expectancy < 1 year
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Palliative care
     
     
     
     
    Presence of CAD or other cardiac disease
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Appropriate for surgery
     
    Persisting severe symptomatic secondary MR
     
    Valve surgery if fulfilling criteria
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    CABG, MV surgery
     
    PCI, TAVI
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Persisting severe symptomatic secondary MR
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Close follow-up
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • End-stage LV, RV failure
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Fulfilling criteria suggesting an increased chance of responding to TEER
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes=TEER
     
    NO
     
     
     
     
    The above algorithm adopted from 2021 ESC Guideline[3]


    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

    Recommendations for intervention in chronic severe secondary mitral regurgitation
    (Class I, Level of Evidence B):

    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

    (Class IIa, Level of Evidence B):

    TEER should be considered in selected symptomatic patients, not suitable for surgery and high likelihood of responding to TEER

    (Class IIa, Level of Evidence C):

    ❑ In symptomatic inoperable patients, PCI (and/orTAVI) possibly followed by TEER (in case of persisting severe secondary MR) should be considered

    (Class IIb, Level of Evidence C) :

    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

    The above table adopted from 2021 ESC Guideline[3]


    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

     
     
     
    Management of patients with severe chronic primary mitral regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptoms
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Determining the risk of surgery
     
     
     
     
     
     
     
     
     
     
    LVEF ≤ 60% or LVESD ≥ 40 mm
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    High risk of futility
     
     
    High risk for surgery or inoperable
     
     
     
     
    Yes
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
    NO
     
     
    Surgery
     
     
     
    New onset AF or SPAP>50 mmHg
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TEER if anatomically suitable, optimal heart failure therapy
     
     
    Surgery (repair whenever possible)
     
     
     
     
    Yes, surgery
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    High likelihood of durable repair, low surgical risk, and LA dilatation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Follow-up
     
    Surgical mitral valve repair
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    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;


    The above algorithm adopted from 2021 ESC Guideline[3]








    I

    Recommendations for intervention in primary mitral regurgitation
    (Class I, Level of Evidence B):

    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%)

    (Class IIa, Level of Evidence B):

    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)

    (Class IIb, Level of Evidence B) :

    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;


    The above table adopted from 2021 ESC Guideline[3]

    O

    Recommendations for intervention in aortic stenosis
    Symptomatic aortic stenosis:
    (Class I, Level of Evidence B):

    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

    (Class IIa, Level of Evidence C):

    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

    (Class III, Level of Evidence C) :

    Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

    Asymptomatic severe aortic stenosis :
    (Class I, Level of Evidence B):

    Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

    (Class I, Level of Evidence C):

    Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

    (Class IIa, Level of Evidence B):

    Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

    (Class IIa, Level of Evidence C):

    Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

    (Class IIa, Level of Evidence B):

    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:

    Type of intervention:
    (Class I, Level of Evidence C):

    Aortic valve interventions should be performed in an experienced center

    (Class I, Level of Evidence B):

    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

    (Class I, Level of Evidence A):

    TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

    (Class IIb, Level of Evidence C):

    ❑ 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


    The above table adopted from 2021 ESC Guideline[3]








    R

    Clinical characteristics Favours TAVI Favours SAVR
    Lower surgical risk _ +
    Higher surgical risk + _
    Younger age _ +
    Older age + _
    Previous cardiac surgery (CABG) + _
    Severe frailty + _
    Endocarditis _ +
    Anatomical and procedural factors
    TAVI feasible via transfemoral approach + _
    Inaccessable Transfemoral approach or SAVR feasible _ +
    Sequelae of chest radiation + _
    Porcelain aorta + _
    High likelihood of severe patient-prosthesis mismatch (AVA <0.65 cm2/m2 BSA) + _
    Severe chest deformity or scoliosis + _
    Unsuitable aortic annular dimensions for TAVI device _ +
    Bisuspid aortic valve _ +
    Unfavourable valve morphology for TAVI (high risk of coronary obstruction due to low coronary ostia or heavy leaflet/LVOT calcification _ +
    Thrombus in aorta or left ventricle _ +
    Concomitant cardiac conditions requiring interventio
    Significant multi-vessel CAD requiring surgical revascularization _ +
    Severe primary mitral valve disease _ +
    Severe tricuspid valve disease _ +
    Significant dilatation/aneurysm of the aortic root and/or ascending aorta _ +
    Septal hypertrophy requiring myomectomy _ +

    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



    The above table adopted from 2021 ESC Guideline[3]



    Y

     
     
     
     
    Valvular AS
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Low-gradient AS
    • Vmax < 4 m/s
    • ΔPm < 40 mmHg
     
     
     
    High-gradient AS
  • Vmax ≥ 4 m/s,
  • ΔPm ≥ 40 mmHg
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    AVA ≤ 1.0 cm2
     
     
     
     
    High flow status
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Moderate AS
  •  
    Yes
  • Assessment of normal flow condition
  •  
     
    NO
  • Severe AS
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Normal flow
     
    Low flow
  • SVi ≤ 35 mL/m2
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Severe AS unlikely
     
    LVEF ≥ 50%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
  • CCT to assess AV calcification
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, CCT to assess AV calcification
     
    Yes, AVA ≤ 1.0 cm2
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Pseudo-severe AS
  •  
     
     
     
     
     
     
     
     
     
     
     

    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



    The above table adopted from 2021 ESC Guideline[3]




    E

     
     
     
    Management of aortic regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Significant enlargement of ascending aorta
     
     
     
    Severe aortic regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Surgery
     
     
     
    Symptoms
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
    NO
  • LVEF≤ 50% or
  • LVESD > 50 mm (or > 25 mm/m2 BSA)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     


    The above algorithm adopted from 2021 ESC Guideline[3]





    D

    Recommendations for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm
    Severe aortic regurgitation (Class I, Level of Evidence B):

    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%

    (Class IIb, Level of Evidence C):

    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

    (Class I, Level of Evidence C) :

    ❑ Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve

    Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation (Class I, Level of Evidence B):

    Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation

    (Class I, Level of Evidence C):

    ❑ Ascending aortic surgery is recommended in patients with Marfan syndrome and ascending aortic diameter ≥ 50 mm

    (Class IIa, Level of Evidence C):

    ❑ Ascending aortic surgery is recommended with ascending aorta size of:

    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

    ❑ 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



    The above table adopted from 2021 ESC Guideline[3]




    W

    Recommendations for management of atrial fibrillation in valvular heart disease
    NOAC (Class I, Level of Evidence A):

    ❑ In AF patients and mitral regurgitation, aortic regurgitation, and aortic stenosis, NOACs are preferred to VKAs for prevention of stroke
    .

    NOAC (Class III, Level of Evidence C):

    NOACs is not recommended in patients with AF and moderate to severe mitral stenosis

    AF ablation:(Class IIa, Level of Evidence A) :

    ❑ 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

    LAA occlusion : (Class IIa, Level of Evidence B)

    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


    The above table adopted from 2021 ESC Guideline[3]





    Q

    Recommendations for management of CAD in valvular heart disease
    Coronary angiography (Class I, Level of Evidence C):

    Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following:

    Coronary CT angiography (Class I, Level of Evidence C):

    Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD

    CABG:(Class I, Level of Evidence C) :

    CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70%

    CABG : (Class IIa, Level of Evidence C)

    CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70%

    PCI : (Class IIa, Level of Evidence C)

    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


    The above table adopted from 2021 ESC Guideline[3]





    D

    Endocarditis prophylaxis

    Recommendations for anticoagulant therapy in valvular heart disease
    NOAC (Class I, Level of Evidence A):

    ❑ 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

    VKA (Class I, Level of Evidence C):

    ❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS

    VKA:(Class IIa, Level of Evidence B) :

    Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement

    NOAC : (Class III: Harm, Level of Evidence B)

    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

    The above table adopted from 2020 AHA Guideline[2]

    Prophylaxis for rheumatic fever


    F

    Recommendations for anticoagulation for atrial fibrillation in valvular heart disease
    NOAC (Class I, Level of Evidence A):

    ❑ 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

    VKA (Class I, Level of Evidence C):

    ❑ Long term VKA oral anticoagulation is recommended in patients with AF and rheumatic MS

    VKA:(Class IIa, Level of Evidence B) :

    Anticoagulation with VKA is reasonable in patients with new onset AF ≤ 3 months after surgical or transcatheter bioprothetic valve replacement

    NOAC : (Class III: Harm, Level of Evidence B)

    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

    The above table adopted from 2020 AHA Guideline[2]

    F

    Median OperativeMortality Rates for Specific Surgical Procedures

    Procedure Mortality rate (%)
    AVR 2.2
    AVR + CABG 4
    AVR + Mitral valve replacement 9
    Mitral valve replacement 5
    Mitral valve replacement + CABG 9
    Mitral valve repair 1
    Mitral valve repair +CABG 5









     
     
     
     
     
     
     
     
    Management of HFrEF
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    (Class I)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    LVEF ≤35% and QRS <130 ms
     
     
     
     
    LVEF >35% or device

    therapy not indicated

    or inappropriate
     
     
     
     
    Sinus rhythm and LVEF ≤35% and QRS ≥130 ms
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    ICD implantation
     
     
     
     
    If symptoms persist, consider therapies (class II)
     
     
     
     
    CRT-D/-P
  • QRS ≥150 ms (Class I)
  • QRS 130-149 ms (Class IIa)
  •  
     
     
     
     
     
     
     
     
     
     






     
     
     
    Management of patients with pulmonary edema
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Oxygen (Class I) or ventilatory support (Class IIa)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Systolic blood pressure ≥110 mmHg
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
    Loop diuretics (Class I) and/or vasodilators (Class IIb)
     
     
     
     
    Signs of hypoperfusion
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Loop diuretics (Class I) and inotropes/vasopressors(Class IIb)
     
    Loop diuretics (Class I)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Congestion relief
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Optimized medical therapy
     
    Renal replacement therapy
     
    The above algorithm adopted from 2021 ESC Guideline





    Recommendations for initial treatment of acute heart failure
    Oxygen, ventilation support (Class I, Level of Evidence C):

    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

    Oxygen, ventilation support (Class IIa, Level of Evidence B):

    ❑ 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

    Diuretics :(Class I, Level of Evidence C) :

    ❑ Intravenous loop diuretics are considered for all admitted patients with acute heart failure presented with signs, symptoms of fluid overload

    Diuretics : (Class IIa, Level of Evidence B)

    ❑ 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

    Vasodilators: (Class IIb, Level of Evidence B)

    ❑ In order to improve symptoms and reduce congestion in patients with AHF and SBP >110 mmHg, vasodilators may be considered as initial therapy

    Inotropic agents : (Class 2b, Level of Evidence C)

    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

    Inotropic agents]] (Class III, Level of Evidence C):

    ❑ Routinely administration of inotropic agents are not recommended , due to safety concerns, unless the patient has symptomatic hypotension and evidence of hypoperfusion

    Vasopressors: (ClassIIb, Level of Evidence B)

    ❑ In patients with cardiogenic shock, a vasopressor, preferably norepinephrine, may be indicated to increase blood pressure and vital organ perfusion

    Anticoagulant therapy: (ClassI, Level of Evidence A)

    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

    Opiates: (ClassIII, Level of Evidence C)

    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;

    The above table adopted from 2021 ESC Guideline

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

    {{familytree| | |E5 | | E01 | |E7 | | |f | | E0

    1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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 (August 2022). "2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". Eur Heart J. doi:10.1093/eurheartj/ehac262. PMID 36017572 Check |pmid= value (help).
    2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 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 (February 2021). "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". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
    3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 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 (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
     
     
     
     
     
     
     
     
     
     
     
    Stable chest pain suspected INOCA
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Non-invasive test more prevalent
    • Invasive test more comprehensive
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Invasive coronary functional testing
     
     
     
     
     
     
     
     
     
     
     
    Stress PET, Stress CMR, Stress echocardiography