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= ''' | ==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> | |||
|- | |||
|} | |||
== ''' | ==SUDDEN CARDIAC DEATH VICTIM== | ||
{| style="cellpadding=0; cellspacing= 0; width: 800px;" | |||
|- | |||
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims''' | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Medical history, Autopsy, Toxicology, Genetic testing ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑ Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority<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> | |||
|- | |||
|} | |||
==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> | |||
|- | |||
|} | |||
== | ==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> | |||
|- | |||
|} | |||
==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> | |||
❑[[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> | |||
|- | |||
|} | |||
< | ==AS== | ||
{{Family tree/start}} | |||
{{Family tree | | | | | | | | | | | | | | | | B01 | | | |B01= V1}} | |||
{{Family tree | | | | | | | | | | | | | |,|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | | |}} | |||
{{Family tree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | |C02 |C01=_ | C02=+|}} | |||
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | | | | D1| | | | | | | | | | | | | | | | | D1 | | | | | | | | | | | | | | | D1= Positive inferior leads| | | |}} | |||
{{Family tree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | |D2 | |D3 | |D4 | | | | | | | |K2 | |K3 | |K4 | | | | | | | | | | |K4=0 |K3=1,2 |D4=3 | D3=1,2|D2=0 | K2=3|}} | |||
{{Family tree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | |F1 | |F1 | |F1 | | | | | | |L1 | | |L2 | |L3 | | | | | | | | | | | | | | | | |F1=V3 |L1=Left lateral |L2= Left posterolateral | L3= V1/1 ratio| | |}} | |||
{{Family tree | | | | | | | | |,|-|^|.| | | |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | G1| | G2| |:| | | | |:| | | | | | | | | | | | | | | | |:| | | | | | | | | | | |G2=+ |G1=_ |}} | |||
{{Family tree | | | | | | | | |!| | |!| | | |:| | | | |:| | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | |H1 | |H2 | |:| | | | |:| | | | | | | | | | | | | | |J1 | | J2| | | | | | | | | | | |J1= <1 |J2=≥1 | H2=Right paraseptal|H1=Right posterior| |}} | |||
{{Family tree | | | | | | | | | | | | |,|-|-|^|.| | | |:| | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | | | H3| | |H4 | |:| | | | | | | | | | | | | | | M1| | |N1 | | | | | | | | | | | |M1=Lead 2, Notched QS | N1=Left posterolateral| H3=_|H4=+ |}} | |||
{{Family tree | | | | | | | | | | | | |!| | | |!| | | |:| | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | }} | |||
{{Family tree | | | | | | | | | | | |H5 | |H6 | | |:| | | | | | | | | | | | | Y1| | Y2| | | | | | | | | |Y2=NO |Y1= Yes |H6=[[Nodo-Hisian]] |H5=Right lateral |}} | |||
{{Family tree | | | | | | | | | | | | | | | | |,|-|-|-|^|.| | | | | | | | | | | |!| | | |!| | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | | | | | | | |j1 | | |j2 | | | | | | | | | |Y3 | |Y4 | | | | | | | | | |Y4=Left paraseptal |Y3=Deep coronary sinus | j1=_| j2=+| }} | |||
{{Family tree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{Family tree | | | | | | | | | | | | | | | | |J3 | | | J4| | | | | | | | | | | | | | | | | | | | | | | | | | |J3=[[Nodo-Hisian]] | |J4=[[Right atrium]] | |}} | |||
{{Family tree/end}} | |||
== | ==a1== | ||
{{Family tree/start}} | |||
{{Family tree| | | | | | A01 | | | |A01= [[Orthodromic AVRT]]}} | |||
{{Family tree| | | | | | |!| | | | | }} | |||
{{Family tree| | | | | | B01 | | | |B01= [[Pre-excitation]] on resting [[ECG]]}} | |||
{{Family tree| | | |,|-|-|^|-|-|-|-|-|-|-|.| | |}} | |||
{{Family tree| | | C01 | | | | | | | | | |C02| |C01= Yes| C02= NO}} | |||
{{Family tree| | | |!| | | | | | | | | | |!| | | | | | | | | |}} | |||
{{Family tree| | |D1 | | | | | | | | | | D2| | | | | | | | |D2= [[Ablation]] candidate, [[patient]] prefers [[ablation]] |D1=[[Ablation]] candidate, willing to undergo [[ablation]] |}} | |||
{{Family tree| | |,|^|-|-|-|-|.| | | | |,|^|-|-|-|-|-|-|-|-|-|-|.|}} | |||
{{Family tree| | |E1 | | | |E2 | | | F1| | | | | | | | |F2 | | | |F1= Yes | E2=Yes|E1=N0 |F2=NO|}} | |||
{{Family tree| |,|^|-|-|.| | | | |!| | | |!| | | | | | | | | | |!| | | | | | }} | |||
{{Family tree| |G1 | | G2| | | H1| |I1 | | | |,|-|-|-|-|+|-|-|-|.| | | |I1= [[Catheter ablation]] (class 1) | H1=[[Catheter ablation]] (class 1)|G2=[[Amiodarone]], [[betablocker]], [[diltiazem]], [[dofetilide]], [[sotalol]], [[verapamil]] (class 2b) |G1=[[Flecainide]] or [[propafenone]] in the absent of [[structural heart disease]] (class 2a) |}} | |||
{{Family tree| |!| | | |!| | | | | | | | | | | | |J1 | | |J2 | | J3| | | | | | | | | J1=[[Betablocker]], [[diltiazem]], [[verapamil]] (class1)|J2=[[Flecainide]], [[propafenone]] in the absent of [[structural heart disease]] (class 2a)|J3= [[Amiodarone]], [[digoxin]], [[dofetilide]], [[sotalol]] (class 2b) }} | |||
{{Family tree| |V1 | |V1 | | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | V1=If ineffective, consider [[ablation]]|}} | |||
{{Family tree| | | | | | | | | | | | | | | | | | | V1| |V1 | |V1 | | | | | | | | | V1=If ineffective, consider [[ablation]] | | | | | | | | | |}} | |||
{{Family tree/end}} | |||
{| style="border: 2px solid #4479BA; align="left" | |||
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Characteristics}} | |||
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favors SAVR}} | |||
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors TAVI}} | |||
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favors palliation}} | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Older]] age/fewer expected remaining years of [[life]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Limited [[life expectancy]] | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[BAV]] | |||
*Subaortic ([[LV outflow tract]]) calcification | |||
*[[Rheumatic valve disease]] | |||
*Small or large [[aortic]] annulus | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Calcific [[AS]] of a [[trileaflet valve]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Mechanical or surgical [[bioprosthetic]] valve preferred | |||
*Concern for [[patient–prosthesis mismatch]] ([[annular]] enlargement might be considered) | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Bioprosthetic]] valve preferred | |||
*Favorable ratio of [[life expectancy]] to valve durability | |||
* In [[TAVI]] [[valve area]] is larger than same size [[SAVR]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Aortic]] dilation | |||
*Severe [[primary MR]] | |||
*Severe [[CAD]] requiring [[bypass grafting]] | |||
*[[Septal hypertrophy]] requiring [[myectomy]] | |||
*[[AF]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe [[calcification]] of the ascending [[aorta]] ([[porcelain aorta]]) | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Irreversible severe [[LV systolic dysfunction]] | |||
*Severe [[MR]] attributable to annular [[calcification]] | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Severe [[lung]], [[liver]], or [[rena]]l disease | |||
*[[Mobility]] issues (high procedural risk with [[sternotomy]]) | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Symptoms]] likely attributable to noncardiac [[conditions]] | |||
*Severe [[dementia]] | |||
*Moderate to severe involvement of ≥2 other [[organ]] systems | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Frailty]] likely to improve after [[TAVI]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Severe frailty unlikely to improve after [[TAVI]] | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Estimated procedural or surgical risk of [[SAVR]] or [[TAVI]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[SAVR]] risk low | |||
*[[TAVI]] risk high | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[TAVI]] risk low to medium | |||
*[[SAVR]] risk high to prohibitive | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Prohibitive [[SAVR]] risk (>15%) or post-[[TAVI]] [[life expectancy]] <1 y | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Valve]] anatomy, annular size, or low [[coronary]] ostial height precludes [[TAVI]] | |||
*Vascular access does not allow [[transfemoral]] [[TAVI]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Previous [[cardiac surgery]] with at-risk [[coronary grafts]] | |||
*Previous [[chest irradiation]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Valve]] anatomy, annular size, or [[coronary]] ostial height precludes [[TAVI]] | |||
*[[Vascular access]] does not allow transfemoral [[TAVI]] | |||
|- | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Goals of Care and [[patient]] preferences and [[values]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Less uncertainty about valve durability | |||
*Avoid repeat intervention | |||
*Lower risk of [[permanent pacer]] | |||
*[[Life]] prolongation | |||
*[[Symptom]] relief | |||
*Improved long-term [[exercise capacity]] and [[quality of life]] | |||
*Avoid [[vascular]] complications | |||
* Longer [[hospital stay]], [[pain]] in [[recovery period]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*Uncertainty about valve durability and possible repeat [[intervention]] | |||
*Higher risk of [[permanent pacer]] | |||
*Life prolongation | |||
*[[Symptom]] relief | |||
*Improved [[exercise capacity]] and [[quality of life]] | |||
* Shorter [[hospital stay]], less postprocedural [[pain]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*[[Life prolongation]] not an important goal | |||
*Avoid [[futile]] or unnecessary diagnostic or therapeutic procedures | |||
*Avoid procedural [[stroke]] risk | |||
*Avoid possibility of [[cardiac pace maker implantation]] | |||
|- | |||
< | |} | ||
{| | |||
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2020 AHA Guideline<ref name="pmid33332149">{{cite journal |vauthors=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C |title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref> | |||
|- | |||
|} | |||
== | {| style="cellpadding=0; cellspacing= 0; width: 800px;" | ||
|- | |||
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of Mechanical Versus Bioprosthetic AVR''' | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence C]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑ Decision should be made based on [[patients]] preference and values after discussion about the risks of [[anticoagulant]] therapy or the need for valve [[re-intervention]]<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> | |||
{| style="cellpadding=0; cellspacing= 0; width: 800px;" | |||
|- | |||
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate''' | |||
== | |- | ||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[AHA guidelines classification scheme|Class I, Level of Evidence A]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑ [[SAVR]] is recommended for symptomatic and asymptomatic severe [[AS]], and any indication for [[AVR]], who are < 65 years and life expectancy >20 year<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> | |||
:< | |- | ||
|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> | |||
|- | |||
|} | |||
<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 |
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 |
(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 |
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 |
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 |
Torsades depointes (Class I, Level of Evidence C) |
❑ Intravenous magnesium with supplementation of potassium is recommended in patients with TdP |
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
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 | 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 |
(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 |
(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 | |
(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 | |
(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 ;
- 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 | 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
❑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 |
(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 |
(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 |
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 |
(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 |
(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 |
(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 |
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 | |
(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 | |
(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 | |
(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 | |
(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 | |
Primary Tricuspid Regurgitation (Class I, Level of Evidence C): | |
❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery | |
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 | |
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 | |
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 surgery
❑Mitral 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
|
The above table adopted from 2021 ESC Guideline[3] |
---|
Abbreviations:
PMC: Percutaneous mitral commissurotomy;
AF: Atrial fibrillation;
LA: Left atrium;
MVA:Mitral valve area ;
- Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
- MVA >1.5 cm²
- Left atrial thrombus
- More than mild mitral regurgitation
- Severe or bi-commissural calcification
- Absence of commissural fusion
- Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
- Concomitant coronary artery disease requiring bypass surgery
P
Management of patients with chronic severe secondary mitral regurgitation | |||||||||||||||||||||||||||||||||||||||
Symptomatic despite medical therapy | |||||||||||||||||||||||||||||||||||||||
*Optimazing medical therapy
| |||||||||||||||||||||||||||||||||||||||
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
| ||||||||||||||||||||||||||||||||||||||
Yes | NO
| ||||||||||||||||||||||||||||||||||||||
Yes
| NO
| ||||||||||||||||||||||||||||||||||||||
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 | |
(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 |
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 | |
(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) | |
(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) |
(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 |
(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 |
(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
| High-gradient AS
| ||||||||||||||||||||||||||||||||||||||||||||||||
AVA ≤ 1.0 cm2 | High flow status | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes | NO
| Yes
| NO
| ||||||||||||||||||||||||||||||||||||||||||||||
Normal flow
| Low flow
| ||||||||||||||||||||||||||||||||||||||||||||||||
Severe AS unlikely | LVEF ≥ 50% | ||||||||||||||||||||||||||||||||||||||||||||||||
NO | Yes
| ||||||||||||||||||||||||||||||||||||||||||||||||
NO, CCT to assess AV calcification | Yes, AVA ≤ 1.0 cm2 | ||||||||||||||||||||||||||||||||||||||||||||||||
Yes
| NO
| ||||||||||||||||||||||||||||||||||||||||||||||||
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] |
---|
- High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
- The definition of Normal flow by pulsed Doppler echocardiography is :
- 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:
E
Management of aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||
Significant enlargement of ascending aorta | Severe aortic regurgitation | ||||||||||||||||||||||||||||||||||||||||
Surgery | Symptoms | ||||||||||||||||||||||||||||||||||||||||
Yes | NO
| ||||||||||||||||||||||||||||||||||||||||
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 |
(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 |
(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 |
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
- 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
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
- 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
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
| |||||||||||||||||||||||||||||||||||||||||
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 |
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
- ↑ 1.0 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). - ↑ 2.0 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). - ↑ 3.00 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 coronary functional testing | Stress PET, Stress CMR, Stress echocardiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||