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| ===Indications for Aortic Valve Replacement=== | | ==Mitral Stenosis== |
| Shown below is an algorithm depicting the indications for [[aortic valve replacement]] (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the [[blood pressure]] is more than 140 mmHg. Patients with [[Aortic regurgitation stages|stage A]] AR do not require any treatment.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|title=2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons|journal=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref>
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| '''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter
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| {{Familytree/start}}
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| {{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= What is the severity of the aortic regurgitation?}}
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| {{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
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| {{Family tree | | | | | | | B01 | | | | | | | | | | | | | | | | | | B02 | B01= <div style="float: left; text-align: center; width:12em"> '''Severe regurgitation''' </div> <div style="float: left; text-align: left; width: 15em; line-height: 150%"> <br> ❑ Vena contracta >0.6 cm <br> ❑ Doppler jet width ≥ 65% of LVOT <br> ❑ Regurgitant volume ≥60 mL/beat <br> ❑ Regurgitant fraction ≥50% <br> ❑ Effective regurgitant orifice ≥ 0.30 cm² <br> ❑ Holodiastolic flow reversal in the proximal abdominal aorta <br> ❑ [[Left ventricle]] dilatation</div>| B02= <div style="float: left; text-align: center; width:18em">'''Progressive regurgitation''' ([[Aortic regurgitation stages|Stage B]]) </div> <div style="float: left; text-align: left; line-height: 150%"> <br> ❑ Vena contracta <0.6 cm <br>❑ Regurgitant volume <60 mL/beat <br> ❑ Regurgitant fraction <50% <br> ❑ Effective regurgitant orifice <0.30 cm² </div>}}
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| {{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
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| {{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03= Is the patient symptomatic?|B04=Is the patient undergoing<br> another surgery?}}
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| {{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | |,|-|^|-|.| }}
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| {{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | C03 | | C04 |C01= Yes <br> ([[Aortic regurgitation stages|Stage D]])| C02=No <br> ([[Aortic regurgitation stages|Stage C]])| C03= No| C04= Yes}}
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| {{Family tree | |!| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | |!| | | |!| | }}
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| {{Family tree | |!| | | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | |!| D01= ❑ LVEF<50% <br> ([[Aortic regurgitation stages|Stage C2]])|D02=❑ The patient is undergoing another surgery| D03= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD > 50mm <br>([[Aortic regurgitation stages|Stage C2]])| D04= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVEDD > 65mm <br>AND <br> ❑ Low surgical risk| D05= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD ≤ 50mm <br>AND <br> ❑ LVEDD ≤ 65mm| D06= <div style="float: left; text-align: left; width:12em">
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| ❑ Perform a periodic [[echocardiogram]] ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br>
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| : ❑ Every 3 -5 years for mild regurgitation
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| : ❑ Every 1 - 2 years for moderate regurgitation
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| ❑ Control [[Hypertension medical therapy|hypertension]] preferably with <br>
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| : ❑ Dihydropyridine [[calcium channel blockers|CCB]], or
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| : ❑ [[ACE inhibitors]] or [[ARB]]s ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])</div> }}
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| {{Family tree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | |!| | }}
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| {{Family tree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | | | | | E07 | 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 IIa]])| E05= AVR ([[ACC AHA guidelines classification scheme|Class IIb]])| E06=❑ Perform a periodic echocardiogram every 6 - 12 months ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<br>❑ Control [[Hypertension medical therapy|hypertension]] preferably with <br>
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| : ❑ Dihydropyridine [[calcium channel blockers|CCB]], or
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| : ❑ [[ACE inhibitors]] or [[ARB]]s ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])| E07= AVR ([[ACC AHA guidelines classification scheme|Class IIa]])}}
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| {{Family tree/end}}
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| ==Acute AR==
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| {{Familytree/start}} | | {{Familytree/start}} |
| {{Family tree | | | | | A01 | | | | A01= What is the cause of acute AR?}} | | {{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
| {{Family tree | | | |,|-|^|-|.| | | | | | | }} | | {{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
| {{Family tree | | | B01 | | B02 | | B01= [[Infective endocarditis]]| B02= [[Aortic dissection]]}} | | {{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
| {{Family tree | | | |!| | | |!| | | | | | | }} | | {{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
| {{Family tree | | | C01 | | C02 | | C01= <div style="text-align: left; width: 13em">Does the patient have AR related [[heart failure]] symptoms?</div>| C02= Emergent surgery<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher = | date = | accessdate = }}</ref> | | {{Family tree | | | D01 | | | | | | | D02 | | | | | | | | | | | D03 | | | | | | | | | }} |
| }} | | {{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }} |
| {{Family tree | |,|-|^|-|.| | | | | | | | | }} | | {{Family tree | E01 | | E02 | | E03 | | | | E04 | | | | | | E05 | | E06 | | E07 | | | }} |
| {{Family tree | D01 | | D02 | | | | D01= Yes| D02= No}} | | {{Family tree | |!| | | |!| | | |!| | | | | |!| | | | | | | | | | | |!| |,|-|^|-|.| | }} |
| {{Family tree | |!| | | |!| | | | | | | | | }} | | {{Family tree | |!| | | |!| | | |!| | | | | F01 | | | | | | F02 | | |!| F03 | | F04 | }} |
| {{Family tree | E01 | | E02 | | | | E01= <div style="text-align: left; width: 13em">Schedule for early aortic valve replacement ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.citation | publisher = | date = | accessdate = 4 March 2014 }}</ref><ref name="Baddour-2005">{{Cite journal | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>| E02= <div style="text-align: left; width: 13em">Administer antibiotics <br> Follow up the patient <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>}} | | {{Family tree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |!| |!| | | |!| | }} |
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