Sandbox:Sara.Zand: Difference between revisions

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==secondary prevention of sudden cardiac death==
==SUDDEN CARDIAC DEATH VICTIM==
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for treatment of [[syncope]]'''
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |''' Recommendations for secondary prevention of sudden cardiac death'''
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Bradyarrhythmia ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]):'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''ICD implantation ([[ESC guidelines classification scheme|Class I, Level of Evidence A]]):'''
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Implantation of  dual chamber permanent pacemaker in chronic bifascicular block but without documented high grade AV block<br>
[[ICD implantation]] is recommended in [[patients]] with documented [[VF]] or hemodynamically not-tolerated [[VT]] in the absence of reversible causes<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Supraventricular tachycardia([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Amiodarone, Catheter ablation ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
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❑ Treatment of arrhythmia based on guideline directed medical theray<br>
❑In [[patients]] with [[VT]]/[[VF]], an indication for [[ICD]], and no contraindication for [[amiodarone]], [[amiodarone]] may be considered when an [[ICD]] is not available,
❑ Uncommon causes of [[syncope]] especially in younger patients <br>
contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]<br>
❑ In [[syncope]] related to [[SVT]] , vasovagal syncope or [[ventricular arrhythmia]] should be investigated <br>
❑In [[patients]] with sustained monomorphic [[VT]] or sustained polymorphic [[VT]]/[[VF]] triggered by a [[PVC]] with similar morphology and an indication
❑ In [[syncope]] related to [[rapid atrail fibrillation]] without preexcitation, [[vasovagal syncope]] and  sinus node dysfunction in the presence of long pause should be considered<br>
for [[ICD]], [[catheter ablation]] may be considered when an [[ICD]] is not available, contraindicated for concurrent [[medical]] reasons, or declined by the [[patient]]
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Ventriculat arrhythmia]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
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{|
! 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>
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==SUDDEN CARDIAC DEATH VICTIM==
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest victims'''
❑ Treatment of underlying cardiac causes of  [[ventricular arrhythmia]] <br>
❑ Making decision for [[ICD implantation]] related to the recurrence of tachyarrhythmia<br>
<span style="font-size:85%;color:red">In ventricular tachycardia with the rate>200 min, the incidence of syncope and near syncope is 65%</span>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Ischemic and non ischemic cardiomyopathy]]:([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|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]]):'''
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Treatment of underlying causes of [[cardiomyopathy]]<br>
Investigation of unexpected [[sudden death]], especially in case of suspicion of [[inherited]] disease, should be made a [[public health]] priority<br>
❑ [[ICD]] implantation in the presence of [[ventricular arrhythmia]] during electrophysiological study<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>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Valvular heart disease]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
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❑ In severe [[aortic stenosis|AS]]  and [[syncope]] the mechanism of [[syncope]] is low cardiac out put<br>
❑Following [[sudden arrhythmic death syndrome]], post-mortem genetic testing in the decedent for additional [[genes]] may be considered <br>
[[Aortic valve replacement]] should be considered in patients with severe [[  AS ]] and [[exersional syncope]]<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Hypertrophic cardiomyopathy]] ([[ACC AHA guidelines classification scheme|Class I , Level of Evidence C]]):'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' ([[ESC guidelines classification scheme|Class III, Level of Evidence B]])'''
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❑ Inadequate data about the relation between [[unexplained syncope]] as the predictor of  [[SCD]]<br>
❑Following [[sudden arrhythmia death syndrome]], [[hypothesis]]-free post-mortem [[genetic]] testing using [[exome]] or [[genome]] sequencing is not recommended
[[ICD]] implantation indicated  only in patients with  recent history of more than one episode of [[syncope]] suspected to be  [[ventricular tachyarrhythmia]]<br>
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{|
! 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>
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==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Arrhythmogenic right ventricular cardiomyopathy]] : ([[ACC AHA guidelines classification scheme|Class I , Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause  ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
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❑ [[ ICD]] indicates in the setting of [[sustain VT]] leading [[syncope]]<br>
The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]]<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Cardiac sarcoidosis]] : ([[ACC AHA guidelines classification scheme|Class I , Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
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❑ [[ICD]] indicates in the presence of [[syncope]] due to [[ventricular tachycardia]] <br>
In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated <br>
❑  Mechanism of [[ventricular tachycardia] is macroreentry around granulomas and triggered activity and automaticity due to [[myocardial inflammation]]<br>
❑ The role of [[immunosuppression therapy]] in decreasing  [[ventricular arrhythmia]] is controversial<br>
❑ In patients with [[AV block]] , [[immunosuppression therapy]] and in irreversible [[AV]] block  [[permanent pacemaker]] is recommended<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Brugada]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|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]])'''
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[[ICD]] implantation in suspected arrhythmia leading [[syncope]]<br>
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Brugada]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|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]])'''
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❑ [[EPS]] may be helpful for finding [[ ventricular arrhythmia]] leading [[syncope]]<br>
❑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>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Brugada]] : ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
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❑ [[ICD]] is not recommended in patients suspected reflex mediated [[syncope]]<br>
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Short QT syndrome]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
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[[ICD]] implantation in the presence of documented [[ventricular arrhythmia]] and family history of [[SCD]]<br>
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
<span style="font-size:85%;color:red"> <span style="color:red"> Short QT syndrome definition:</span> QTc interval≤340 ms  </span><br>
<span style="font-size:85%;color:red">Syncope is not the risk factor of SCD in the absent of documented VT or VF </span>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Long QT syndrome]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]])'''
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{|
! 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>
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==post cardiac arrest survivors==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for evaluation of sudden cardiac arrest survivors'''
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Extra cardiac cause  ([[ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
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❑ [[Beta-blocker]] therapy in patients with frequent episodes of [[syncope]] reduces risk of fatal arrhythmia specially in [[LQTS1]] <br>
The investigation of a [[SCA]] survivor without obvious extra-[[cardiac]] cause is recommended by a [[multidisciplinary team]]<br>
<span style="font-size:85%;color:red"> Long QT syndrome definition:<span style="color:red"></span> QTc interval ≥ 500 ms </span>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Long QT syndrome]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Coronary angiogram ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
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❑[[ICD]] implantation in [[syncope]] related [[arrhythmia]] in patients are on [[betablocker]] or intolerant to [[betablocker]]<br>
In [[electrically]] unstable [[patients]] after [[SCA]], with suspicion of ongoing [[myocardial ischemia]], a [[coronary angiogram]] is indicated <br>
❑ Left cardiac sympathectomy in frequent episodes of [[syncope]] arrhythmia in patients are on [[betablocker]] or intolerant to [[betablocker]] ([[LOR]]=C)<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CPVT]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|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]])'''
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[[Exercise]] restriction in patients suspected [[arrhythmia]] leading [[syncope]]<br>
❑In [[SCA]] survivors, [[brain]]/[[chest]] [[CT scan ]] should be considered when [[patient]] characteristics, [[ECG]], and [[echocardiography]] are not consistent with a [[cardiac]] cause<br>
[[Betablocker]] therapy for reduction of [[sympathetic activity]] in [[stress]]-induced [[tachyarrhythmia]]<br>
<span style="font-size:85%;color:red"> CPVT definition:<span style="color:red"></span> catecholamine-induced (often exertional) bidirectional VT or polymorphic VT in the setting of a structurally normal heart and normal resting ECG </span>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CPVT]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|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]])'''
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❑ [[Flecainide]] in patients with arrhythmia leading [[syncope]] in spite of [[betablocker]] therapy<br>
❑In [[SCA]] survivors, collection of [[blood]] samples at presentation is recommended for potential [[toxicology]] and [[genetic]] testing<br>
❑[[ICD]] implantation in patients with [[arrhythmia]] leading [[syncope]] in spite of optimal medical therapy ([[LOR=B)<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>
|-
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CPVT]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Echocardiography ([[ESC guidelines classification scheme|Class IC, Level of Evidence B]])'''
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|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Verapamil]] in patients with [[arrhythmia]] leading [[syncope]] during exercise  in spite of [[betablocker]] therapy<br>
❑[[Echocardiography]] is recommended to evaluate [[cardiac]] structure and function in all [[SCA]] survivors
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Vasovagal syncope]] : ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Coronary vasospasm ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
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❑Avoidance of triggers(prolonged standing, warm environments, coping with dental and medical setting<br>
❑In [[SCA]] survivors, [[ergonovine]], [[acetylcholine]], or [[hyperventilation]] testing may be considered for the diagnosis of [[coronary vasospasm]]
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Vasovagal syncope]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
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{|
! 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>
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==vt storm==
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of electrical storm'''
❑ Supine position for prevention of faint and injury in  short prodrome phase <br>
❑ Physical counter maneuvers (leg crossing, limbs or abdominal  contraction, sqqadding in long prodrome phase<br>
❑ [[Midodrine]] in recurrent [[vasovagal syncope]] without history of [[hypertension]], [[heart failure]], [[urinary retension]]<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Vasovagal syncope]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''Sedation  ([[ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
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|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
Lacking evidence about benefit of orthostasis training such as repeating [[tilt table test]] until negative result or 30-60 minutes standing against a wall daily <br>
Mild to moderate [[sedation]] is recommended in [[patients]] with the [[electrical storm]] to reduce [[psychological]] distress and reduce [[sympathetic]] tone
[[ Flodrocortisone]] in patients with inadequate response to [[salt]], [[fluide intake]]<br>
❑ [[Betablocker]] in patients  with recurrent vasovagal syncope ,older than 42 years<br>
❑ Elimination or reduction the medications causing [[hypotension]] and [[syncope]]<br>
[[Selective serotonin reuptake inhibitors]] such as [[fluoxetine]] ,[[paroxetine]] for prevention of recurrent [[vasovagal syncope]]<br>
❑ [[Dual chamber pacing]] in patients older than 40 years and recurrent [[syncope]] with pause > 3 seconds related with [[syncope]] or asymptomatic pause >6 seconds<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[Carotide sinus syndrome]] : ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Cardiac pacemaker implantation]] in recurrent [[cardioinhibitory]] or mixed [[syncope]]<br>
❑ [[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 |''' [[Carotide sinus syndrome]] : ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
Dual chamber pacemaker in older patients with underlying sinus node dysfunction or conduction abnormality<br>
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>
|}
===Recommendation for [[syncope]] due to [[dehydration]] and medications===
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[AHA guidelines classification scheme#Classification of Recommendations|Class I, Level of evidence:C]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Procainamide  ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|-
|bgcolor="LemonChiffon"|[[Fluid rescucitation ]] orally or intravenous is useful for [[syncope]] related to [[hypotension]] or exercise associated hypotension due to [[peripheral vasodialation]]
|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
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[AHA guidelines classification scheme#Classification of Recommendations|Class IIa, Level of evidence:B]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Intubation ([[ESC guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|-
|bgcolor="LemonChiffon"| Reducing or withdrawing medications causing hypotension and [[syncope]] such as [[diuretics]], [[vasodilators]], [[venodilators]], [[sedatives]], [[negative chronotropes]]
|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>
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[AHA guidelines classification scheme#Classification of Recommendations|Class IIa, Level of evidence:C]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Quinidine ([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]])'''
|-
|-
|bgcolor="LemonChiffon"| [[Salt and fluid intake ]] in [[syncope]] due to [[dehydration]]
|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="border: 2px solid #4479BA; align="left"
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Uncommon conditions associated with syncope}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Clinical aspect}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Cause of syncope}}
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Cardiac [[tamponade]]
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for acute management of sustained VT'''
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hypotension]], [[tachycardia]], [[cardiogenic shock]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Tachycardia]], [[hypotension]], [[abrupt bradycardia]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Constrictive pericarditis]]
|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; background: #F5F5F5; text-align: left;" | [[heart failure symptoms]], [[exertional dyspnea]], [[orthopnea]], [[edema]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cough syncope]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Left ventricular non compaction]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Trabeculation and recess in [[left ventricle]]
[[DC cardioversion]] is recommended as the first-line therapy for [[hemodynamically]] not-tolerated [[sustained monomorphic ventricular tachycardia]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Tachyarrhythmia]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Takotsubo]] cardiomyopathy
|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; background: #F5F5F5; text-align: left;" | Apical ballooning , [[basal hyperkinesia]] , following stressful event, [[chest pain]] and [[ECG]] change mimicking [[ischemia]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Uncommon cause of [[syncope]], multifactorial
|-
|-
|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="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Pulmonary embolus]]
|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; background: #F5F5F5; text-align: left;" |  [[Cardiac arrest]] and [[pulseless electrical activity]] following [[hypoxia]], [[tachycardia]], [[hypotension]] and [[shock]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bradycardia]], [[hypotension]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Pulmonary arterial hypertension]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Exertional [[syncope]], specially in younger patients
❑ 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="padding: 0 5px; background: #F5F5F5; text-align: left;" | Peripheral vasodilation following exercise, low [[cardiac output]] state
|-
|-
|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; background: #F5F5F5; text-align: left;" | [[Amyloidosis]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Amyloid deposition in [[heat]], [[kidney]], [[peripheral]] and autonomic nervous system
❑In [[patients]] presenting with a hemodynamically tolerated [[sustained monomorphic VT]] and presence of [[structural heart disease]], intravenous [[procainamide]] should be considered
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AV block]], [[arrhythmia]], [[low cardiac output]] due to restrictive [[cardiomyopathy]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hemochromatosis]]
|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; background: #F5F5F5; text-align: left;" | [[Dilated cardiomyopathy] due to Iron deposition 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocardial involvement]], [[sick sinuse syndrome]], [[AV block]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Myocarditis]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Chest pain]], [[arrhythmia]], [[left ventricular systolic dysfunction]], [[hemodynamic collapse]]
❑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="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Ventricular tachycardia]], [[AV block]], [[transient hemodynamic collapse]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Lyme ]] disease
|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; background: #F5F5F5; text-align: left;" | [[Myocarditis]] accompanied by erythma migrant, neurologic involvement
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AV block]], [[vasovagal |syncope]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Chagas| disease]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cardiomyopathy]]  caused by trypanosomiasis
❑Intravenous [[verapamil]] is not recommended in wide [[QRS]] complex tachycardia of unknown mechanism
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ventricular tachycardia]], [[AV block]]
|-
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Friedreich ataxia]]
|}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Hypertrophic Cardiomyopathy ]] ([[HCM]]), [[gait ataxia]], [[bladder dysfunction]]  
{|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Tachycardia]], [[bradycardia]], [[SCD]] is common
! 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;" | [[Cardiac tumors]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Age]]/[[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Triad of [[ valve obstruction]] , [[emboli]], [[systemic signs and symptoms]]  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Younger]] [[age]]/longer [[life expectancy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Obstruction to [[blood flow]]
| 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;" | [[Prosthetic valve thrombosis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Valve]] [[anatomy]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Asymptomatic or symptomatic [[heart failure]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Embolic event, valve obstruction
*[[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;" | [[Anomalous coronary artery]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prosthetic valve]] preference
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Common cause of [[exertional syncope]] and [[SCD]] specially in young athletes]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bezold jarisch reflex]],[[hypotension], [[VT], [[AV block]]  
*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;" | [[Subclavian steal syndrome]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Concurrent [[cardiac]] [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Significant stenosis in [[subclavian artery]] leading [[flow reversal]] in [[vertebral artery]] and [[vertebrobasilar ischemia]] and [[syncope]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Syncope]] following upper extremities activity
*[[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;" | [[Aortic dissection ]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Noncardiac [[conditions]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Neurologic symptoms]], [[heart failure symptoms]], [[myocardial infarction]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Increased risk of inhospital death, [[tamponade]], [[neurologic deficit]] in patients with [[syncope]]
| 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;" | [[Coarctation of the aorta |COA]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Frailty]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[heart failure symptoms]], [[dissection of aorta]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Not frail or few [[frailty]] measures
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Associated with [[bicuspid aortic valve ]] stenosis
| 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;" | [[Rheumatoid arthritis]]
| 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;" | [[Systemic inflammatory disorder]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Complete heart block]]
*[[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;" | [[Carcinoid syndrome]],[[Pheochromocytoma]], [[Mastocytosis]], [[ Vasoactive intestinal peptide tumor]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Procedural]] specific impediments
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Vasodilation]], [[flushing]], [[pruritus]], [[gastrointestinal symptoms]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Transient hypotension]]
*[[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;" | [[Beta thalassemia major]]
| 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;" | [[Dilated cardiomyopathy ]], severe [[anemia]], multiple organ failure
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[ Arrhythmia]]
*Less uncertainty about valve durability
|-
*Avoid repeat intervention
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Migraine]]
*Lower risk of [[permanent pacer]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Association between [[headache]] and [[syncope]]
*[[Life]] prolongation
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Vasovagal [[syncope]], [[orthostase intolerance]]
*[[Symptom]] relief
|-
*Improved long-term [[exercise capacity]] and [[quality of life]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Seizure]]-induced [[bradycardia]], [[hypotension]]
*Avoid [[vascular]] complications
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Temporal lobe]] [[epilepsy]]
* Longer [[hospital stay]], [[pain]] in [[recovery period]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Postictal [[bradyarrhythmia] due to [[temporal lobe]] or [[limbic system]]
| 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>
|-
|}
|}
{{clear}}




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{| 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>




Line 300: Line 519:




{| 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>
|-
|}




{{familytree/start |summary=PE diagnosis Algorithm.}}
<span style="font-size:85%">'''Abbreviations:'''
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= [[TGA]], [[TAPVR ]],[[Truncus arteriosus]] |A02= Infusion of [[Prostaglandin]], [[Diuretic]] therapy }}
'''SAVR:''' [[ Surgical aortic valve replacement]];
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
'''TAVI:''' [[Transcutaneous aortic valve implantation]];
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= [[TOF]]|B02= Hydration, modified [[ blalock taussing shunt]], insertion stent in [[PDA]] and [[right ventricular outflow tract]], total repair  }}
'''AS:''' [[Aortic stenosis]];
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
'''LVEF:'''[[Left ventricular ejection fraction]] ;
{{familytree | | | | | | C01 |-|+|-| C02 |-| C03 | | | |C01= Treatment of Cyanosis |C02= Ebstein anomaly |C03= [[Tricuspid valve]] repair }}
</span>
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
<br>
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01= [[Hypoplastic left heart syndrome]] |D02=  Infusion of [[Prostaglandin]] for keeping patency of [[ductus arteriosus]], infusion of vasodilator for reduced systemic resistance, [[mechanical ventilation]] in shock state and imposing [[hypercapnia]] and [[alveolar hypoxia]] for increased [[pulmonary resistance]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01= [[Sepsis]], [[shock]], low [[cardiac output]] state, [[cold exposure]], [[metabolic disorder]], [[polycythemia]]|D02= Treatment of underlying disorder}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01= [[Eisenmenger syndrome]] with [[pulmonary hypertension]],|D02= [[Phosphodiesterase-5 inhibitor ]] ([[sildenafil]], [[tadalafil]], [[Endothelin receptor antagonist]] ([[ bosentan]],[[ macitentan]], [[ambrisentan]])}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}


{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01= Methemoglobinemia |E02=  Infusion of [[ Methylenblue]],[[dextrose]],[[N-acetyl cystein]],[[cimethidin]],[[ ketoconazole]]
*Contraindications for [[percutaneous mitral commissurotomy]] in [[rheumatic mitral stenosis]]
}}
*[[MVA]] >1.5 cm²
{{familytree/end}}
*[[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




Line 333: Line 584:




===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.
|}






PAO2 is the mean alveolar oxygen pressure.PH2O is the water vapor pressure (47 mmHg at 37°C).
===c1===


PaCO2 is the alveolar carbon dioxide tension. It is assumed to be equal to arterial PCO2.


R is the respiratory quotient and is approximately 0.8 at steady state on standard diet.
{{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>
|-
|}


FiO2 is the fractional concentration of inspired oxygen. It is 0.21 at room air.Normal PAO2 is:
===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>


PAO2 = FiO2× (Pb − PH2O) − (PACO2/R).
{|
! 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>
|-
|}


=0.21× (760 − 47) (40/0.8).
===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>


=100 mmHg.
|}
{|
! 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}}


{{familytree/start}}
{|
{{familytree | | | | | | | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | |C01= Mechanism of [[hypoxemia]] | }}
! 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>
{{familytree | | | | | | | | | | | |,|-|-|-|-|-|-|-|v|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| | | | | | | }}
|-  
{{familytree | | | | | | | | | | | G01 | | | | | | G02 | | | | | | | | | | | | | | G03 | | | | |G01=<div style="float: left; text-align: left; width: 22em; padding:1em;"> '''V/Q mismatch:'''<br>
|}
❑ Common cause of [[hypoxemia]]<br>
❑ High proportion in apex of the [[lung]] due to higher [[ventilation]] compared with [[perfusion]]  <br>
❑ Easily corrected by supplemental [[oxygen]] therapy<br>
❑ widened (A-a )oxygen gradient<br>
❑ High [[V/Q mismatch]] such as [[ pulmonary embolism ]] that [[ventilation]] is higher than [[perfusion]]<br>
❑ [[Asthma]]<br>
❑ [[COPD]]<br>
❑ [[Bronchectasia]]<br>
❑ [[Cystic fibrosis]]<br>
❑ [[Interstitial lung disease]] ([[ILD]])<br>
❑ [[Pulmonary hypertension]] due to [[lung]] disease<br>


'''Diffusion limitation''':<br>
❑ Normal PCO2 level<br>
❑ Good response to [[oxygen]] therapy <br>
❑ widened P(A-a)O2 level<br>
❑ Alveolocapillary impairment<br>
❑ [[ILD]]<br>
❑ [[Emphysemia]]<br> </div>|G02=<div style="float: left; text-align: left; width: 22em; padding:1em;"> '''Right to left shunt:'''<br>
❑ Poor response to [[oxygen]] therapy<br>
❑ Normal PCO2 level<br>
❑ Widened P(A-a) O2 gradient<br>
❑ Presence of Small physiologic pulmonary shunt about 2-3% of [[cardiac output]] due to deraining of [[bronchial veins]] into [[pulmonary veins]] and deraining coronary veins into [[left ventricle]]<ref name="pmid13685279">{{cite journal |vauthors=AVIADO DM, DALY MD, LEE CY, SCHMIDT CF |title=The contribution of the bronchial circulation to the venous admixture in pulmonary venous blood |journal=J. Physiol. (Lond.) |volume=155 |issue= |pages=602–22 |date=March 1961 |pmid=13685279 |pmc=1359878 |doi=10.1113/jphysiol.1961.sp006650 |url=}}</ref><br>
❑ If the [[shunt fraction]] reaches 50%, [[hypercapnia]] may be present <br>
❑ Shunt fraction<20% if PaO2/FIO2>200<br>
❑ Shunt fraction>20% if PaO2/FIO2<200<br>
❑ Cyanotic [[congenital heart disease]] with right to left shunt<br>
❑ [[Pneumonia]]<br>
❑ [[Pulmonary edema]]<br>
❑ [[Acute respiratory distress syndrome]]([[ARDS]])<br>
❑ [[Alveolar collapse]]<br>
❑ [[Pulmonar arterionenous connection]]<br></div>|G03=<div style="float: left; text-align: left; width: 22em; padding:1em;"> '''[[Hypoventilation]]:'''<br>
❑ High PCO2 level<br>
❑ Low [[ventilation]] leading to Low PAO2, PaO2 level<br>
❑ Normal P(A-a)O2 gradient due to normal alveolar capillary memberane<br>
❑ longstanding hypoventilation leading to atelectasia and widened P(A-a)O2 gradient<br>
❑ Corrected by supplemental oxygen therapy<br>
❑ One Cause of [[respiratory failure]] in [[COPD]], [[Asthma]],[[ILD]]<br>
❑ ''Disorders leading to [[hypoventilation]] include'':<br>
❑ ''Impaired central drive'':<br>
:❑ [[Opiom overdose]], [[benzodiazepine]], [[alcohol]]<br>
:❑ [[Brain stem infarct]], [[hemorrhage]]<br>
:❑ Primary alveolar hyperventilation 
❑ ''Spinal cord level'':
:❑[[Amiotrophic lateral sclerosis]]
:❑[[Cervical spinal cord injury]]
❑''nerve supplying respiratory muscle'':
:❑[[ Guillain-Barre syndrome]]
❑ ''Neuromascular junction'':
:❑[[Myasteni-Graves]]
:❑[[Lambert-eaton syndrome]]
❑''Respiratory muscle'':
:❑[[Myotony]]
❑'' Defect in chest wall'':
:❑[[Kyphoscoliosis]]
:❑[[Thoracoplasty]]
:❑[[Fibrothorax]]


</div>}}{{family tree/end}}                       
<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>




Line 425: Line 792:




===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>




Line 438: Line 935:




{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Management of cyanotic congenital heart disease:'''<br>
----
:❑ Measurement of [[oxygen saturation]] at rest( about 5 min) rather than after walking <br>
:❑ Using air filter for all venous access<br>
:❑ [[Cerebral imaging]] in the presence of new [[headache]] or any [[neurologic signs]] for evaluation of [[brain abcesss]],[[hemorrhage]], [[stroke]]<br>
:❑ Checking serum uric acid in patients with history of [[gout]]
:❑ Supplement oxygen<br>
:❑ Avoidance of excess [[oxygen]] supplement or narcotic due to reduction hypoxia-mediated derived to ventilation <br>
:❑ Adequate [[hydration]] and movement during the long flight, NO need for checking oxygen saturation before flight<br>
:❑ Measurement of coagulation parameters(Activated partial thromboplastin time,international normalized ratio,thrombin time) in hematocrite>55%<br>}}




{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 17em; width: 30em; padding:1em;"> ''' Important points in treatment of eisenmenger disease:'''<br>
----
:❑ [[Bosentan]] for treatment of symptomatic [[VSD]], [[ASD]], [[PDA]],[[Aortopulmonary window]],[[ Complex congenital heart disease]],[[Down syndrome]]([[CLASS 1 Recommendation]])<br>
:❑ [[Phosphodiesterase-5 inhibitor]]( [[Tadalafil]],[[sildenafil]]) for treatment of Symptomatic [[ASD]], [[VSD]], [[Great artries shunt]]([[CLASS 2a Recommendation]])<br>}}




'''CYANOSIS.https://doi.org/10.1016/j.chest.2017.11.003
===D===
PMID: 19561940  PMID: 16764526 
PMID: 15545679'''
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= [[Eisenmenger disease]]  |A02=[[Increased pulmonary vascular resistant]] leading to right to left [[shunt]], systemic [[arterial desaturation]], [[central cyanosis]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=[[Tamponad]] |B02=low [[cardiac output]], [[low stroke volume]], [[elevated cardiac filling pressures]], increased [[sympathetic tone]]( [[tachycardia]], [[peripheral vasoconstriction]], peripheral cyanosis)}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | C01 |-|-|!| | | | | | | C01= Diagnosis of peripheral and [[central cyanosis]]|}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Pulmonary thromboembolism]] |D02= [[Pulmonary artery vasoconstriction]], [[hypoxia]], [[right ventricle]] pressure overload, right to left shunt via [[patent foramen ovale]],[[central cyanosis]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| R1  |-| R2  | | | | | | | | |R1=[[ Cardiogenic shock]] |R2= Decreased [[myocardial perfusion]], muscle [[hypoxia]],necrosis, impaired [[myocardial contraction]]., decreased [[cardiac out put]], Increased vasoconstrictor,[[ peripheral cyanosis]] | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| G01 |-| G02 | | | | |G01=[[Tetralogy of fallot]]| G02= Episods of [[Tet spell] between 2-4 months of age, aggravated with [[crying]] ,[[feeding]], [[stooling]], ]]dehydration]], in patients with severe [[pulmonary stenosis]] and large [[VSD]], [[central cyanosis]| }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| H01 |-| H02 | | | | | | | | | H01=[[ Methemoglubinemia ]]|H02= Increased level of reduced [[hemoglobin]],[[normal oxygen saturation]], [[congenital]] or  due to [[medication]], [[central cyanosis]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| I01 |-| I02 | | | | | | | | |I01=[[Chronic obstructive pulmonary disease]] |I02= [[Central cyanosis]], [[respiratory failure]], PO2<60 mmHg, PCO2>45mmHg while breathing at sea level, [[prepheral edema]] due to [[right heart failure]] |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| J01 |-| J02 | | | | | | | | | | | | | | | | | | | | |J01= [[Pulmonary edema]]| J02= [[Decreased arterial oxygen saturation]], [[central cyanosis]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| F01 |-| F02 | | | | | | | | |F01=[[High altitude]] |F02=[[Hypoxia]], peripheral [[cyanosis]] due to [[ischemia]] and [[occlusion]] small peripheral vessels, [[central cyanosis]] due to [[pulmonary edema]] in [[acute mountain sickness]], [[pulmonary hypertension]] in [[chronic mountain sickness]] |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| L01 |-| L02 | | | | | | | | | L01= [[Pneumonia]] | L02=[[ Central cyanosis]] due to impaired gas exchange and [[intrapulmonary shunt]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=[[ ARDS]] |E02= Acute pulmonary parenchimal disease other than [[cardiac]] origin or [[volume overload]], [[alveolar]] filling with [[exudates]] or [[alveolar collapse]], [[central cyanosis]] due to  decreased [[oxygen saturation]] and intrapulmonary shunting  }}
{{familytree/end}}




{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{| 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: #4682B4; color: #FFFFFF;" align=center |''' Cyanosis in [[Congenital heart disease]]'''
|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: #B8B8B8" align=left | ''' Cyanosis + pulmonary edema at the time of birth:'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
[[TGA]] ([[Transposition of great vessel]]) without associated [[PDA]],[[VSD]],[[ ASD]], two great arteries are misplaced, oxygenated pulmonary blood re-enter the pulmonary circulation via morphologic [[left ventricle]] and deoxygenated  aorta blood re-enter  the systemic circulation via morphologic [[right ventricle]]  <br>
❑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>
[[Total anomalous pulmonary venous connection]]([[TAPVR]]),connection between [[pulmonary veins]] and right system and mixing the oxygenated and deoxygenated blood  <br>
[[Truncus arteriosus]], one great vessel arise from both ventricle then the gives rise to the aorta and pulmonary artery<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Cyanosis +[[shock]] and [[collapse]] within hours or days after birth:'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
[[Tetralogy of fallot]]: [[pulmonary stenosis]] (valvular, subvalvular) with [[ventricular septum defect]] and overridding [[aorta]]<br>
❑A [[mechanical prosthesis]] may be considered in [[patients]] already on long-term [[anticoagulation]] due to the high risk for [[thromboembolism]]<br>
❑ Severe [[ pulmonary stenosis]] with intact ventricular septum<br>
❑ [[Ebstein anomaly]]: small functional [[right ventricle]], huge [[right atrium]], severe [[tricuspid regurgitation]], right to left shunt from [[ASD]] or [[PFO]]<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''Cyanosis +[[shock]] and [[collapse]] in the first week of birth:'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
[[Hypoplastic left heart syndrome]]<br>
❑A [[bioprosthesis]] is recommended according to the desire of the informed [[patient]]<br>
❑ Severe [[coarctation of aorta]]<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>
❑ Severe [[aortic stenosis]] <br>
❑A [[bioprosthesis]] is recommended in case of reoperation for [[mechanical valve]] [[thrombosis]] despite good [[anticoagulation]]<br><br>
[[Tachycardia]] induced [[cardiomyopathy]] due to [[atrial flutter]] or [[PSVT]]<br>
[[Dilated cardiomyopathy]]<br>
<span style="font-size:85%;color:red">[[Other differential diagnosis|<span style="color:red"> Other differential diagnosis:</span>]] [[neonate sepsis |<span style="color:red"> neonate sepsis,</span>]] [[ menangitis|<span style="color:red"> menangitis</span>]] or [[hypoglycemia|<span style="color:red">hypoglycemia</span>]] </span>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Differencial cyanosis ( upper limbs O2 saturation > lower limbs O2 saturation):'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Severe [[pulmonary hypertension]] with [[PDA]]<br>
❑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>
❑ Severe [[aortic coactation]] or interruption <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: #B8B8B8" align=left |''' Differencial cyanosis ( lower limbs O2 saturation> upper limbs O2 saturation):'''
|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|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
[[TGA]] + severe [[pulmonary hypertension]] + [[PDA]] <br>
❑A [[bioprosthesis]] may be considered in [[patients]] already on long-term [[NOACs]] for whom are high risk for [[thromboembolism]]<br>
[[TGA]] + severe [[aortic arch interruption]] + [[PDA]]<br>
|
❑ Connection right [[subclavian artery]] to right [[pulmonary artery]] <span style="font-size:85%;color:red">[[Right upper limb saturation|<span style="color:red"> Right upper limb oxygen saturation</span>]] [[is lower |<span style="color:red"> is lower</span>]] [[ than|<span style="color:red"> than </span>]]  [[ left upper and left lower limbs oxygen saturation|<span style="color:red"> left upper and left lower limbs oxygen saturation</span>]] </span>
|}
|}}
{|
! 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>
|-
|}




{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
<span style="font-size:85%">'''Abbreviations:'''
{{Family tree/start}}
'''[[TAVI]]:''' [[Transcatheter aortic valve implantation]];
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Differentiating [[cardiac]] and [[pulmonale]] causes of cyanosis at birth:'''<br>
'''AF:''' [[Atrial fibrillation]];
----
'''NOAC:''' [[Non-vitamin K antagonist oral anticoagulant]];
[[History]] and [[physical exam]] <br> ❑ [[Blood pressure]] measurement in four [[limbs]] <br> ❑ [[Oxygen saturation]] measurement  <br> ❑ [[ECG]]  <br> ❑ [[Chest-X-ray]] </div>}}
{{familytree  | | | | | |!| | | | | |}}
{{familytree  | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Cardiac cause:'''<br>
----
[[Cardiomegaly]] in [[CXR]] <br>  ❑ Relatively comfortable at rest <br> ❑Cyanosis may worsen with [[crying]]<br> ❑ Cardiac [[murmur]]<br> ❑ Abnormal [[rhythm]] or axis in [[ECG]]<br> ❑  Normal [[Pco2]] level<br> ❑  NO response to [[O2]] therapy  <br> </div>}}
{{familytree  | | | | | |!| | | | | |}}
{{familytree  | | | | | D01 | | | | |D01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Pulmonary cause:'''<br>
----
[[Respiratory distress]],[[ tachypnea]] at rest<br>❑ [[Rale]], [[crackle]], [[wheezing]] in [[chest]] [[auscultation]]<br>❑ Normal [[cardiac margin]] in [[CXR]]<br>❑ [[Ground glass]] appearance, [[pneumonia]], [[atelectasia]],[[ pneumothorax]] in [[CXR]]<br>❑ Normal [[ECG]] finding<br>❑ Elevated [[PCO2]] level<br>❑ Corrected with [[oxygen]] therapy<br></div>}}{{familytree/end}}


</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>
|-
|}




Line 565: Line 1,067:




====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>
|-
|}




Line 583: Line 1,120:




===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]]




Line 600: Line 1,181:




===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>
|-
|}


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01= [[Heart failure]]  |A02=[[Increased capillary permeability]] from  Systemic venous hypertension,volume overload  }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=[[Hepatic disease]] |B02=[[Increased capillary permeability]] from systemic venous hypertension, decreased oncotic pressure}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | C01 |-|-|!| | | | | |C01=Mechanism of [[Edema]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Chronic venous insufficiency]] |D02= [[venous reflux]], poorly functioning [[venous valves]], incompetent venous valves, reduced venous return, blood pooling, [[hypoxia]], and [[inflammation]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| R1  |-| R2  | | | | | | | | |R1=[[Lymphedema]] |R2=[[Lymphatic obstruction]],[[lymph node]] dissection,[[malignancy],[[filariasis]]| }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| G01 |-| G02 | | | | |G01=[[Cellulitis]]| G02=Increased [[capillary permeability]}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| H01 |-| H02 | | | | | | | | | H01=[[ Obstructive sleep apnea ]]|H02=[[Pulmonary hypertension]], increased [[ capillary hydrostatic pressure]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| I01 |-| I02 | | | | | | | | |I01=[[ Renal disease]] |I02=Increased [[ plasma volume]], decreased [[plasma oncotic pressure]] from [[protein loss]] |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| J01 |-| J02 | | | | | | J01=[[Protein losing entropathy]]| J02= Decreased plasma oncotic pressure}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| F01 |-| F02 | | | | | | | | |F01=[[Deep vein thrombosis]] |F02=[[Increased capillary permeability]] |}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| L01 |-| L02 | | | | | | | | | L01= [[Cellulitis]] | L02=[[Increased capillary permeability]] }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=[[Pregnancy]] |E02= Increased [[plasma volume ]]  }}
{{familytree/end}}


<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>








{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start}}
{{familytree  | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; height: 25em; width: 17em; padding:1em;"> '''Laboratory Tests should be obtained:'''<br>


:❑ [[Complete blood count]]
:❑ [[Urinalysis]]
:❑ [[Blood sugar]]
:❑ [[Creatinine]]
:❑ [[Thyroid-stimulating hormone]]
:❑ [[Serum Albumin]]
:❑ [[D-dimer]]
:❑ [[B-type-natriuretic peptides]]
:❑ [[Aspartate aminotransferase]]
:❑ [[Alanine aminotransferase]]
:❑ [[Total Bilirubin]]
:❑ [[Prothrombin time]]
:❑ [[Alkaline phosphatase]]}}








===T===


{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{{Family tree/start}}
|-
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 33em; width: 17em; padding:1em;"> '''Medications Associated With Edema:'''<br>
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''
----
:❑ [[Monoamine oxidase inhibitors]], [[trazodone]]
:❑ [[Beta-adrenergic blockers]], dihydropyridine [[calcium channel blockers]],[[ clonidine]] , [[hydralazine]], [[methyldopa]], [[minoxidil]]
:❑ [[Acyclovir]]
:❑[[ Cyclophosphamide]], [[cyclosporine ]](Sandimmune), [[cytosine arabinoside]],[[ mithramycin]]
:❑ [[Androgen]], [[corticosteroids]], [[estrogen]], [[progesterone]],[[ testosterone]]
:❑ [[Celecoxib]], [[ibuprofen]] 
:❑ [[Pioglitazone]],[[rosiglitazone]]
:❑ [[Levofloxacin]]
:❑ [[Citalopram]]}}


|-
|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>


{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
|-
{{Family tree/start}}
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 40em; width: 25em; padding:1em;"> '''Diagnostic tools:'''<br>
|-
----
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
:❑ [[Duplex sonography]] in patients with unilateral lower limb swelling and positive D-dimer, or high clinical suspicion of      thrombosis
In [[symptomatic]]  inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered<br>
:❑ Abdominal or [[pelvic CT scan]] in patients with [[lower limb swelling]] and evidence of [[malygnancy]]
|-
:❑ [[Magnetic resonance venography]] of the lower leg in patients with unilateral [[leg swelling]]  
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
with out evidence of [[thrombosis]] on [[duplex ultrasonography]] if there is high clinical suspicion for [[deep venous thrombosis]]
|-
:❑ [[Echocardiography]] in patients with  [[ obesity]], [[obstructive sleep apnea]], and [[edema]] for evaluation of [[pulmonary arterial pressures]] and also in patients with evidence of[[ heart failure]] for assessment of[[ ejection fraction]] and [[pulmonary artery pressure]] and [[structural heart disease]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
:❑[[Ankle-brachial index]] in patients with [[chronic venous insufficiency]] and [[cardiovascular risk factors]] before compression therapy, which is contraindicated in [[peripheral arterial disease]]}}
❑ [[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>
|-
|}


==Do's==


<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>


**
**
**
**
**
**
**
**
**
**


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


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Line 714: Line 1,312:




===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>
|-
|}




{{family tree|end}}












{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=Congestive heart failure |A02=diuretic,sodium restriction }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=Nephrotic syndrome |B02= diuretic  }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | C01 |-|+|-| C02 |-| C03 | | |C01=Edema treatment |C02=Lymphedema |C03= compression stocking, skin care,manual lymphatic derenage,bandage,exercise program with compression }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=Chronic venous insufficiency |D02= compression stocking,bandage/wraps,adjunctive devices,pneumatic pumps}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=Lipedema |E02= Suction lipectomy  }}
{{familytree/end}}




Line 746: Line 1,370:




===I===






{{familytree/start |summary=PE diagnosis Algorithm.}}
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=[[Congestive heart failure]] |A02= [[loop diuretic]],[[sodium restriction]] }}
|-
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01=[[Nephrotic syndrome]] |B02= Loop diuretic  }}
|-
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | C01 |-|+|-| C02 |-| C03 | | |C01=[[Edema]] treatment |C02=Lymphedema |C03= [[Compression stocking]],[[ skin care]],[[manual lymphatic deraning]],bandage }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Chronic venous insufficiency]] |D02= [[Compression stocking]],bandage,wraps,adjunctive devices,pneumatic pumps}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| F01 |-| F02| | | | | | | | | | | |F01=[[Deep vein thrombosis]] | F02=[[ Anticoagulant therapy]],early walking, [[compression stocking]]| }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| G01 |-| G02 | | | | |G01=[[Cellulitis]]| G02=[[ Antibiotic theraphy]]}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=[[Lipedema]] |E02= [[Suction lipectomy]]  }}
{{familytree/end}}


|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>
|-
|}




Line 784: Line 1,537:




===R===


{{familytree/start}}
{| style="border: 2px solid #4479BA; align="left"
{{familytree | | | | | | | | | | | | | | A01 | | |||||||||||||||||||||||A01=Pulse examination}}
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Clinical characteristics}}
{{familytree | | | | | | | | | | B01 |-|.|!|,|-| B02 | | | | | | | |||||||||||||B01= Ulcer|B02= lymphadenopathy/masses}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Favours TAVI}}
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |||||||||||C01= Pitting|C02= Physical examination|C03= Unilateral/bilateral}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Favours SAVR}}
{{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | ||||||||||D01= Skin condition,texture,color|D02= Distribution}}
|-
{{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | | | |||||||||||E01= Temperature}}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lower [[surgical]] risk
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
{{familytree/end}}
| 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]]


{{familytree/start}}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
{{familytree | | | | | | | | | | | | | | A01 | | |||||||||||||||||||||||A01=Associated injury/illness}}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
{{familytree | | | | | | | | | | B01 |-|.|!|,|-| B02 | | | | | | | |||||||||||||B01= Recent surgery/procedure|B02= Malygnancy}}
|-
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |||||||||||C01= Painful|C02= History|C03= Onset(acute,chronic)}}
| 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]]
{{familytree | | | | | | | | | | D01 |-|'|!|`|-| D02 | | | | | | | ||||||||||D01= Aggravated by activity|D02= Underlying illness}}
{{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | | | |||||||||||E01= Change in medications}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}


| 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]]


{{familytree/start}}
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
{{familytree  | | | | | C01 | | | | | C01=<div style="float: left; text-align: left; height: 25em; width: 17em; padding:1em;"> '''Laboratory test:'''<be>
| 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]]


:❑ Complete blood count
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | _
:❑ Urinalysis
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | +
:❑ Blood sugar
|-
:❑ Creatinine
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Septal [[hypertrophy]] requiring [[myomectomy]]
:❑ Thyroid-stimulating hormone
:❑ Serum Albumin
:❑ D-dimer
:❑ BNP
:❑ AST
:❑ ALT
:❑ Total Bilirubin
:❑ Prothrombin time
:❑ Alkaline phosphatase
{{familytree/end}}


   
| 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>
|-
|}




Line 836: Line 1,669:




===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


== Overview ==








===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>
|-
|}








{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''Medications associated with edema:'''<be>
----
:❑ Monoamine oxidase inhibitors, trazodone
:❑ Beta-adrenergic blockers, calcium channel blockers, clonidine , hydralazine, methyldopa, minoxidil
:❑ Acyclovir
:❑ Cyclophosphamide, cyclosporine (Sandimmune), cytosine arabinoside, mithramycin
:❑ Androgen, corticosteroids, estrogen, progesterone, testosterone
:❑ Celecoxib, ibuprofen  }}
:❑Pioglitazone,roziglotazone
:❑ Levofeloxain






{{Family tree/start}}
<nowiki>{{familytree  | | | | | B01 | | | | | B01=</nowiki><div style="float: left; text-align: left; height: 30em; width: 40em; padding:1em;"> '''mechanisms of edema :'''<br>


----
===D===
:❑ [[Cardiac disease]]: Increased [[capillary permeability]] from systemic venous hypertension; increased [[plasma volume]]
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
:❑ [[Hepatic disease]]: Increased capillary permeability from systemic venous hypertension; decreased[[ plasma oncotic pressure]] from reduced [[protein synthesis]]
|-
:❑ [[Malabsorption]]/protein-calorie[[ malnutrition]]: Reduced [[protein synthesis]] and decreased plasma [[oncotic pressure]]
| 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 '''
:❑ [[ Obstructive sleep apnea ]][[Pulmonary hypertension]], increased[[ capillary hydrostatic pressure]]
|-
:❑ [[Pregnancy]] and [[premenstrual ]]edema: increased [[plasma volume ]]
|style="font-size: 100; padding: 0 5px; background: #FFB6C1" align=left | '''Severe aortic regurgitation ([[ ESC  guidelines classification scheme|Class I, Level of Evidence B]]):'''
:❑[[ Renal disease]]: Increased plasma volume, decreased [[plasma oncotic pressure]] from [[protein loss]]  
|-
:❑ Chronic venous insufficiency: [[venous reflux]], poorly functioning [[venous valves]], incompetent venous valves, reduced venous return, blood pooling, [[hypoxia]], and [[inflammation]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
:❑[[Lymphedema]]: lymphatic obstruction in upper [[extremities]] due to [[breast cancer]] and [[lymph nodes dissection]], rich in [[protein]]
[[Surgery]] is recommended in symptomatic [[patients]] regardless of [[LV]] function<br>
:[[Cellulitis]]: Increased [[capillary permeability]]
❑ [[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%
:[[Deep vein thrombosis]]: Increased [[capillary permeability]/div}}
|-
|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>
|-
|}




Line 891: Line 1,844:




{{familytree/start |summary=Sample 10}}{{familytree/start |summary=PE diagnosis Algorithm.}}
{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 25em; width: 25em; padding:1em;"> '''Diagnostic approach:'''<br>
----
:❑ Magnetic resonance venography of the lower extremity and pelvis should be obtained in patients with unilateral left leg swelling and negative results on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis
:❑ Echocardiography should be performed in patients with obesity, obstructive sleep apnea, and edema to evaluate pulmonary arterial pressures.
:❑ Ankle-brachial index should be measured in patients with chronic venous insufficiency and cardiovascular risk factors before initiation of compression therapy, which is contraindicated in peripheral arterial disease/div>}}


===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>
|-
|}


{{Family tree/start}}
{{familytree  | | | | | B01 | | | | | B01=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Treatment:'''<br>
----
:❑ Compression stockings should be used in patients following deep venous thrombosis to prevent postthrombotic syndrome
:❑ Pneumatic compression devices should be used in conjunction with standard therapy in patients with lymphedema
: ❑ Daily hydration with emollients and short courses of topical steroid creams for severely inflamed skin should be used to treat eczematous (stasis) dermatitis associated with chronic venous insufficiency>
:❑ Anticoagulation therapy in deep vein thrombosis/div}}




Line 916: Line 1,895:




===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>
|-
|}




Line 929: Line 1,958:




===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==
{| class="wikitable sortable"
{| style="border: 2px solid #4479BA; align="left"
!Inherited causes of cardiac arrest  and malignant arrhythmia associated covid-19
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|Procedure}}
![[long QT syndrome]]
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Mortality rate (%)}}
![[Brugada]] syndrome
![[Short QT syndrome]]
![[Cathecolaminergic polymorphic ventricular tachaycardia]]
|-
|-
|Gene mutation
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[AVR]]
|
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |    2.2
* ''[[KCNQ1]]([[LQT1]])'',
|-
| 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}}
 
 
 
 
 
 
 
 


* ''[[KCNH2]]([[LQT2]])'',


* ''[[SCN5A]]([[LQT3]])''
<br />
|
* loss of function in [[SCN5A]] in %30 of patients
|
* ''[[KCNH2]]([[SQT1]])'',


* ''[[KCNQ1|KCNQ1(SQT2)]]''


* ''[[KCNJ2|KCNJ2(SQT3)]]''
|
* [[RYR2]]([[CPVT1)]]


* [[CASQ2]](CPVT2)


* [[KCNJ2]](CPVT3)


|-
|[[EKG]] finding
|
* [[QTc]]>450ms in men


* [[QTc]]>470ms in women
{{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}}


* [[T waves alternance]]
|
* Coved-type ST-segment elevation


* T-wave inversion


in lead V<sub>1</sub> and/or V<sub>2</sub>
|
* [[QTc]]<330 msec
|
* Normal [[EKG]]
*[[Bradycardia]]


* mild [[u waves]]
|-
|Specific considerations in [[COVID19]]  patients
|
* causion in administration of  QT prolongation drugs([[hydroxychloroquine]], [[azithromycin]] lupinavir/ritonavir)


* Controlling the fever for prevention of QT prolongation
* Avoidance of using≥ one drugs inducing QT prolongation<br />
|
* Controlling the [[fever]] as the main cause of cardiac arrest in brugada syndrome, especially in children less than 5 year old
|
* Safety of [[hydroxychloquine]] due to prolongation of QT interval in [[short QT syndrom type 1]] ([[KCNH2]] related) and type3([[KCNJ2]])
|




* Avoidance of  administration of [[epinephrine]], [[isoproterenol]], and dobutamine, all α and/or B1 receptor agonists inducing  ventricular arrhythmia


* Controlling the sress related to COVID-19
*Safety of flecainide without any interaction with lopinavir, ritonavir and [[chloroquine]].


|-
|fatal arrhythmia
|
* [[Torsade de pointes]]


*[[Ventricular fibrillation]]
{{Family tree/start}}
|
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with [[pulmonary edema]]}}
* [[Ventricular fibrillation]],  
{{Family tree | | | | |!| | | | | }}
* Polymorphic VT
{{Family tree | | | | A01 | | | |A01= [[Oxygen]] (Class I) or [[ventilatory support]] (Class IIa)}}
|[[Ventricular fibrillation]]
{{Family tree | | | | |!| | | | | }}
|
{{Family tree | | | | B01 | | | |B01= [[Systolic blood pressure]] ≥110 mmHg}}
*[[Bidirectional VT]]
{{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
|-
|}
|}






* Corrected QT(QTc)=1000(QT/1000+0.154(1-RR)


* QT, QTc  are measured in milliseconds)


* RR is measured in seconds and is  the interval from the onset of one QRS complex to the onset of the next QRS complex
 
 
 
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for initial treatment of acute heart failure'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support  ([[ 2021 ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Oxygen]] is recommended in [[hypoxic]] [[patients]] with  [[SpO2]]<90% or [[PaO2]] <60 mmHg<br>
❑ [[Intubation]] is recommended in the presence of progressive [[respiratory failure]] in spite of [[oxygen]] administration or non-invasive [[ventilation]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Oxygen]], [[ventilation]] support ([[ 2021 ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[respiratory distress]] ([[respiratory rate]] >25 breaths/min, SpO2<90%), [[non-invasive]] [[positive pressure ventilation]] is recommended to decrease [[respiratory distress]] and reduce the rate of mechanical [[endotracheal intubation]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] :([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ Intravenous [[loop diuretics]] are considered for all admitted [[patients]] with [[acute heart failure]] presented  with [[signs]], [[symptoms]] of [[fluid]] overload<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Diuretics]] : ([[ESC guidelines classification scheme|Class IIa, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with resistant [[edema]] who do not respond to an increase in [[loop diuretic]] doses, combination of a [[loop diuretic]] with [[thiazide]] type [[diuretic]] should be considered <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasodilators]]: ([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In order to improve [[symptoms]] and reduce [[congestion]] in  [[patients]] with [[AHF]] and SBP >110 mmHg, [[vasodilators]] may be considered as initial therapy<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Inotropic agents]] : ([[ESC guidelines classification scheme|Class 2b, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Inotropic]] agents may be considered in [[patients]] with [[SBP]] <90 mmHg and evidence of [[hypoperfusion]] without response to fluid challenge, to improve [[peripheral
perfusion]] and maintain [[end-organ]] function<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Inotropic]] agents]] ([[ESC guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑  Routinely administration of [[inotropic]] agents are not recommended , due to safety concerns, unless the [[patient]] has [[symptomatic hypotension]] and evidence of [[hypoperfusion]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Vasopressors]]: ([[ESC guidelines classification scheme|ClassIIb, Level of Evidence B]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[cardiogenic shock]], a [[vasopressor]], preferably [[norepinephrine]], may be indicated to increase [[blood pressure]] and vital [[organ]] perfusion<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Anticoagulant therapy]]: ([[ESC guidelines classification scheme|ClassI, Level of Evidence A]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Thromboembolism prophylaxis]] such as [[LMWH]] is recommended in [[patients]] not already [[anticoagulated]] and no contraindication to [[anticoagulation]], to prevent the risk of [[deep venous thrombosis]] and [[pulmonary embolism]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[Opiates]]: ([[ESC guidelines classification scheme|ClassIII, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Opiates]] is not routinely recommended, unless in selected [[patients]] with severe, intractable [[pain]] or [[anxiety]]<br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''AHF:''' [[Acute heart failure]];
'''LMWH:''' [[Low-molecular-weight heparin]];
'''PaO2:''' [[Partial pressure of oxygen]]  ;
'''SpO2:''' [[Transcutaneous oxygen saturation]];
</span>
<br>
 
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline
|-
|}
 
== Approach to stable [[chest pain]] and [[ischemia]] and no obstructive [[CAD]] ([[INOCA]])==
 
{{familytree/start}}
{{familytree| | | | | | | | | | | | A01 | | | | | |A01=Stable [[chest pain]] suspected [[INOCA]]}}
{{familytree| | | | | | | | | | | | |!| | | | | | | | }}
{{familytree| | | | | | | | | | | | B01 | | | | | |B01=Non-invasive test more prevalent
*Invasive test more comprehensive}}
{{familytree| | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree| | | | | C01 | | | | | | | | | | | |C02|C01=[[Invasive coronary functional testing]]|C02=[[Stress PET]], [[Stress CMR]], [[Stress echocardiography]]}}
{{familytree| | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|-|+|-|-|-|v|-|-|-|-|.| |}}
{{familytree| | |E5 | | E01 | |E7 | | |f  | |  E0

Latest revision as of 09:30, 16 September 2022

secondary prevention of sudden cardiac death

SUDDEN CARDIAC DEATH VICTIM

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

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

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

❑In patients with VT/VF, an indication for ICD, and no contraindication for amiodarone, amiodarone may be considered when an ICD is not available, contraindicated for concurrent medical reasons, or declined by the patient
❑In patients with sustained monomorphic VT or sustained polymorphic VT/VF triggered by a PVC with similar morphology and an indication for ICD, catheter ablation may be considered when an ICD is not available, contraindicated for concurrent medical reasons, or declined by the patient

The above table adopted from 2022 ESC Guideline[1]

SUDDEN CARDIAC DEATH VICTIM

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

❑ Investigation of unexpected sudden death, especially in case of suspicion of inherited disease, should be made a public health priority
❑In cases of sudden death, it is recommended to collect a detailed description of circumstances of death, symptoms prior to death, the family history, and to review prior medical files
❑A comprehensive autopsy is recommended, ideally, in all cases of [[unexpected sudden death], and always in those,50 years of age
❑In cases of SCD, it is recommended to retain samples suitable for DNA extraction and consult with cardiac pathologist when an inherited cause is suspected or the cause of death unexplained
Toxicology screens are recommended in sudden death cases with the uncertain cause of death
❑For SCD where the cause is known or suspected to be heritable, genetic testing targeted to the cause is recommended
❑Following SADS (sudden arrhythmic death syndrome), post-mortem genetic testing targeted to primary electrical disease is recommended when the decedent is young (,50) and/or the circumstances and/or family history support a primary electrical disease
❑When an autopsy diagnoses possible heritable cardiac disease, it is recommended to refer first-degree relatives for cardiac assessment
❑In non-autopsied cases of sudden death where inherited cardiac disease is suspected, it is recommended to refer first-degree relatives for cardiac assessment

(Class IIb, Level of Evidence C) :

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

(Class III, Level of Evidence B)

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

The above table adopted from 2022 ESC Guideline[1]

post cardiac arrest survivors

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

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

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

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

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

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

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

❑In SCA survivors, collection of blood samples at presentation is recommended for potential toxicology and genetic testing
❑Retrieval of recordings from CIEDs and wearable monitors are recommended for all SCA survivors
❑In SCA survivors, repeated 12-lead ECGs during stable rhythm (including high precordial lead [[ECG]), as well as continuous cardiac monitoring, are recommended
Coronary imaging and CMR with LGE are recommended for evaluation of cardiac structure and function in all SCA survivors without a clear underlying cause
Sodium channel blocker test and exercise testing is recommended in SCA survivors without a clear underlying cause

Echocardiography (Class IC, Level of Evidence B)

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

Coronary vasospasm (Class IIb, Level of Evidence B)

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

The above table adopted from 2022 ESC Guideline[1]




post cardiac arrest survivors

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

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

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

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

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

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

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

❑In SCA survivors, collection of blood samples at presentation is recommended for potential toxicology and genetic testing
❑Retrieval of recordings from CIEDs and wearable monitors are recommended for all SCA survivors
❑In SCA survivors, repeated 12-lead ECGs during stable rhythm (including high precordial lead [[ECG]), as well as continuous cardiac monitoring, are recommended
Coronary imaging and CMR with LGE are recommended for evaluation of cardiac structure and function in all SCA survivors without a clear underlying cause
Sodium channel blocker test and exercise testing is recommended in SCA survivors without a clear underlying cause

Echocardiography (Class IC, Level of Evidence B)

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

Coronary vasospasm (Class IIb, Level of Evidence B)

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

The above table adopted from 2022 ESC Guideline[1]

vt storm

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

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

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

Antiarrhythmic therapy with beta-blockers (non-selective preferred) in combination with intravenous amiodarone is recommended in patients with structural heart disease and electrical storm unless contraindicated
Catheter ablation is recommended in patients presenting with incessant VT or electrical storm due to sustained monomorphic VT refractory to antiarrhythmic drugs

Torsades depointes (Class I, Level of Evidence C)

❑ Intravenous magnesium with supplementation of potassium is recommended in patients with TdP
Isoproterenol or transvenous pacing to increase heart rate is recommended in patients with acquired LQT syndrome and recurrent TdP despite correction of precipitating conditions and magnesium

Procainamide (Class IIa, Level of Evidence B)

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

Intubation (Class IIa, Level of Evidence C)

❑Deep sedation/intubation should be considered in patients with an intractable electrical storm non-responsive drug treatment

Catheter ablation should be considered in patients with recurrent episodes of VT/VF triggered by a similar PVC, refractory to medical treatment or coronary revascularization

Quinidine (Class IIb, Level of Evidence C)

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

The above table adopted from 2022 ESC Guideline[1]

vt

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

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

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

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

Supraventricular tachycardia (Class IIa, Level of Evidence C)

❑ In patients presenting with a regular hemodynamically tolerated wide QRS complex tachycardia suspected for supraventricular tachycardia, administration of adenosine or vagal maneuvers should be considered

Procainamide (Class IIa, Level of Evidence B)

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

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

❑In patients presenting with a hemodynamically tolerated sustained monomorphic VT in the absence of significant structural heart disease, flecainide, ajmaline, or sotalol may be considered

Verapamil (Class III, Level of Evidence B)

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

The above table adopted from 2022 ESC Guideline[1]

polymorphic vt

 
 
 
Polymorphic Ventricular arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Underlying etiology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute ischemia
 
External precipitating factors
 
Polymorphic Ventricular Arrhythmia triggered by unifocal PVC
 
Acquired long QT
 
 
 
 
 
 
 
Primary electrical disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approach to STEMI
 
Treatment of underlying condition (Class I)
 
Catheter ablation (Class IIa)
 
 
Remove precipitating factors (Class I)
  • Mg++/K+ i.v.(Class I)
  • Isoproterenol (Class I)
  • Pacing (Class I)
  •  
     
     
    Brugada, Early repolarization syndrome
     
    Idiopathic VF
     
    Long QT, CPVT
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Recurrent Ventricular arrhythmia
     
     
     
    Recurrent Ventricular arrhythmia
     
    Recurrent Ventricular arrhythmia
     
     
    Isoproterenol (Class IIa)
     
    Isoproterenol (Class IIa)
  • Quinidine (Class IIa)
  • Verapamil (Class IIa
  • Catheter ablation of PVC triggers (Class IIa)
  •  
    Beta-blocker (Class I)
  • Pacing (Class I)
  • Mg++/K+ i.v (Class I)
  • Antiarrhythmic drugs according to underlying disease (Class 2a)
  • Autonomic modulation (Class 2a)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Deep sedation/ intubation (Class IIa)
     
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
     
    Recurrent ventricular arrhythmia
     
    Recurrent ventricular arrhythmia
     
    Recurrent ventricular arrhythmia
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Deep sedation/ intubation (Class IIa)
     
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
    Deep sedation/ intubation (Class IIa)
  • Mechanical circulatory support (Class IIb)
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    The above algorithm adopted from 2022 ESC Guideline[1]

    AS

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

    a1


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







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












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

    ❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve re-intervention
    ❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

    (Class IIa, Level of Evidence B):

    ❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy
    ❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors
    ❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

    (Class IIb, Level of Evidence B):

    ❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

    The above table adopted from 2020 AHA Guideline[2]

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










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

    SAVR is recommended for symptomatic and asymptomatic severe AS, and any indication for AVR, who are < 65 years and life expectancy >20 year
    ❑Either SAVR or transfemoral TAVI is recommended in symptomatic severe AS who are 65-80 years after evaluation about life expectancy and valve durability
    TAVI is recommended in symptomatic severe AS who are >80 years or younger patients with life expectancy <10 years and no anatomic contraindication for transfemoral TAVI
    TAVI is recommended in symptomatic patients with severe AS in any age and high surgical risk or prohibitive for surgery when predicted survival is > 12 months after TAVI with acceptable quality of life

    (Class I, Level of Evidence B):

    SAVR is recommended in preference to TAVI in asymptomatic severe AS and abnormal exercise stress test, very severe AS, rapid progression, and elevated BNP
    ❑ In asymptomatic severe AS in age ≤ 80 years of age and LVEF < 50 and no anatomic contraindications for transfemoral TAVI, making decision between TAVI and SAVR is similar to symptomatic patients

    (Class I, Level of Evidence C):

    ❑For symptomatic severe AS when predictive survival is <12 months after TAVI or SAVR and minimal improvement in quality of life is expected, palliative care is recommended

    (Class IIb, Level of Evidence C):

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

    The above table adopted from 2020 AHA Guideline[2]


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







    b1

    Class Level Recommendations
    I C Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
    IIa B-NR Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
    IIa C Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.


    c1

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

    Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice

    The above algorithm adopted from 2020 AHA Guideline[2]

    a1

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

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

    The above algorithm adapted from 2020 AHA Guideline[2]

    A

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

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

    (Class IIa, Level of Evidence B):

    Fibrinolysis (using recombinant tissue plasminogen activator 10 mg bolus + 90 mg in 90 min with UFH or streptokinase 1500 000 U in 60 min without UFH) should be considered when surgery is very high risk or is not available , or for thrombosis of right-sided prostheses

    (Class IIa, Level of Evidence C):

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

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

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

    (Class IIa, Level of Evidence B):

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

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

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

    (Class IIa, Level of Evidence B):

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

    (Class IIa, Level of Evidence C):

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

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

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

    (Class IIa, Level of Evidence B):

    ❑ Desion of Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team based on anatomic considerations, features of the prosthesis, and high risk patients for surgery or inoperable patients

    (Class IIb, Level of Evidence B):

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

    (Class IIa, Level of Evidence C):

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

    The above table adopted from 2021 ESC Guideline[3]


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

    B

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


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





    C

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

    ❑It is recommended discontinuation of VKA prior to elective surgery to aim for an INR <1.5
    ❑Bridging of OAC is recommended in patients with any of the following:

    ❑In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to initiate either UFH or LMWH 12-24 h after surgery
    ❑ Maintaning aspirin therapy , if indicated, is recommended in patients undergoing surgery during the periprocedural period
    ❑In patients treated with DAPT after recent PCI (within 1 month) requiring heart valve surgery in the absence of an indication for OAC, starting the P2Y12 inhibitor postoperatively is recommended

    (Class I, Level of Evidence B):

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

    (Class I, Level of Evidence C):

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

    (Class IIb, Level of Evidence C):

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

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

    ❑If the risk of stent thrombosis is low, in patients undergone PCI or after ACS requiring long-term OAC, early cessation (≤1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended
    ❑ In patients treated with an OAC, discontinuation of antiplatelet treatment is recommended after 12 months

    (Class IIa, Level of Evidence C):

    ❑If the risk of stent thrombosis is high, in patients undergone PCI or after ACS requiring both OAC and antiplatelet therapy, triple therapy with aspirin, clopidogrel and OAC for longer than 1 week should be considered with the total duration (≤1 month)

    (Class IIa, Level of Evidence B):

    ❑In patients with mechanical heart valve treated with a VKA and low risk for stent thrombosis and HAS-BLED ≥ 3 , clopidogrel alone should be considered for up to 12 months
    ❑In patients requiring aspirin and/or clopidogrel in addition to VKA, target INR should be considered in the lower part of the recommended target

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

    ❑For all patients with an mechanical heart valve prosthesis, OAC using a VKA is recommended lifelong
    ❑ For patients with biological heart valve, OAC is recommended if they have other indications for anticoagulation

    (Class IIa, Level of Evidence B):

    ❑ In patients with biological heart valve and AF, NOACs should be considered over VKA after 3 months following surgical implantation
    ❑ In patients with an aortic biological heart valve, low-dose aspirin (75-100 mg/day) or OAC using a VKA should be considered for the first 3 months after surgical implantation
    ❑ In patients with a mitral or tricuspid biological heart valve, OAC using a VKA should be considered for the first 3 months after surgical implantation

    (Class IIb, Level of Evidence C):

    ❑ In patients with mechanical heart valve and evidence of atherosclerotic disease and low risk of bleeding, The addition of low-dose aspirin (75-100 mg/ day) to VKA may be considered in selected patients
    NOACs may be considered over VKA within 3 months following surgical implantation of a biological heart valve in mitral position in patients with AF

    (Class IIa, Level of Evidence C):

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

    (Class III, Level of Evidence B):

    NOACs are not recommended in patients with a mechanical valve prosthesis

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

    OAC with VKA should be considered during the first 3 months after mitral and tricuspid repair
    SAPT with low-dose ASA (75-100 mg/day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications to

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

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

    (Class I, Level of Evidence A):

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

    (Class III, Level of Evidence B):

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

    The above table adopted from 2021 ESC Guideline[3]


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









    D

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

    ❑A mechanical prosthesis is recommended according to the desire of the informed patient and NO contraindications to long term anticoagulation
    ❑A mechanical prosthesis is recommended in patients at risk of structural valve deterioration

    (Class IIa, Level of Evidence C):

    ❑A mechanical prosthesis should be considered in patients already on anticoagulation because of a mechanical prosthesis in another valve position
    ❑A mechanical prosthesis should be considered in patients with a reasonable life expectancy and high risk for redo valve surgery or TAVI

    (Class IIa, Level of Evidence B):

    ❑A mechanical prosthesis should be considered in patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position

    (Class IIb, Level of Evidence C):

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

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

    ❑A bioprosthesis is recommended according to the desire of the informed patient
    ❑A bioprosthesis is recommended when anticoagulant theray is contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation and low life expectancy
    ❑A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good anticoagulation

    (Class IIa, Level of Evidence C):

    ❑A bioprosthesis should be considered in patients for whom there is a low likelihood and/or a low operative risk of future redo valve surgery
    ❑A bioprosthesis should be considered in young women in the age of pregnancy
    ❑A bioprosthesis should be considered in patients aged >65 years for a prosthesis in the aortic position or aged >70 years in a mitral position

    (Class IIb, Level of Evidence B):

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

    The above table adopted from 2021 ESC Guideline[3]


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


    G

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

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

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

    Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery
    Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction

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

    Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery
    Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery

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

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

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

    Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery
    Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension

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

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

    The above table adopted from 2021 ESC Guideline[3]








    =F

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

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

    The above algorithm adopted from 2021 ESC Guideline[3]








    K

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

    PMC is recommended in symptomatic patients with favourable characteristics for PMC

    (Class I, Level of Evidence C):

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

    (Class IIa, Level of Evidence C):

    PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy and favourable clinical characteristics for PMC
    PMC should be considered in asymptomatic patients with favourable clinical and anatomical characteristicsc for PMC and:

    The above table adopted from 2021 ESC Guideline[3]


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






    P

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


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





    T

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

    Valve surgery/intervention is recommended in symptomatic severe secondary MR despite GDMT or CRT
    ❑Valve surgery is recommended in patients undergoing CABG or other cardiac surgery

    (Class IIa, Level of Evidence B):

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

    (Class IIa, Level of Evidence C):

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

    (Class IIb, Level of Evidence C) :

    Valve surgery may be considered in symptomatic patients who are appropriate for surgery
    ❑In high-risk symptomatic patients not eligible for surgery and low likelihood of responding to TEER, making decision about TEER procedure or other transcatheter valve therapy and evaluation for ventricular assist device or heart transplant should be considered

    The above table adopted from 2021 ESC Guideline[3]


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







    U

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

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


    The above algorithm adopted from 2021 ESC Guideline[3]








    I

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

    Mitral valve repair is considered when the results of surgical technique are expected to be durable
    Surgery is recommended in low risk symptomatic patients
    Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD ≥ 40 mm and/or LVEF ≤ 60%)

    (Class IIa, Level of Evidence B):

    Surgery is recommended in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg)
    Surgical mitral valve repair is recommended in low-risk asymptomatic patients with LVEF > 60%, LVESD <40 mmd and significant LA dilatation (volume index ≥60 mL/m2 or diameter ≥55 mm)

    (Class IIb, Level of Evidence B) :

    TEER may be considered in symptomatic patients who are inoperable due to high surgical risk, with echocardiographic criteria of eligibility

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


    The above table adopted from 2021 ESC Guideline[3]

    O

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

    Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)
    ❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

    (Class IIa, Level of Evidence C):

    Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction
    Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

    (Class III, Level of Evidence C) :

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

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

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

    (Class I, Level of Evidence C):

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

    (Class IIa, Level of Evidence B):

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

    (Class IIa, Level of Evidence C):

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

    (Class IIa, Level of Evidence B):

    Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:

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

    Aortic valve interventions should be performed in an experienced center

    (Class I, Level of Evidence B):

    SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI
    SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

    (Class I, Level of Evidence A):

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

    (Class IIb, Level of Evidence C):

    ❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI. ❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

    Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity


    The above table adopted from 2021 ESC Guideline[3]








    R

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

    Abbreviations: AV: Aortic valve; AVA: Aortic valve area; LVOT: Left ventricular outflow tract ; SAVR: Surgical aortic valve replacement; TAVI: Transcatheter aortic valve implantation; BSA: Body surface area; CAD: Coronary artery disease



    The above table adopted from 2021 ESC Guideline[3]



    Y

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

    Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity



    The above table adopted from 2021 ESC Guideline[3]




    E

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


    The above algorithm adopted from 2021 ESC Guideline[3]





    D

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

    Surgery is recommended in symptomatic patients regardless of LV function
    Surgery is recommended in asymptomatic patients with LVESD > 50 mm or LVESD > 25 mm/m2 BSA (in patients with small body size) or resting LVEF ≤ 50%

    (Class IIb, Level of Evidence C):

    Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤ 55%, in low risk condition
    ❑Aortic valve repair may be considered in selected patients at experienced centres when durable results are expected

    (Class I, Level of Evidence C) :

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

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

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

    (Class I, Level of Evidence C):

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

    (Class IIa, Level of Evidence C):

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

    Risk factors: family history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension , aortic size increase >3 mm/year

    ❑ In the presence of primarily indication for the surgery of aortic valve, replacement of the aortic root or tubular ascending aorta should be considered when ≥ 45 mm

    Abbreviations: BSA: Body surface area; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; LVESV:Left ventricular end-systolic diamete



    The above table adopted from 2021 ESC Guideline[3]




    W

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

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

    NOAC (Class III, Level of Evidence C):

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

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

    ❑ Concomitant AF ablation should be considered in patients undergoing valve surgery with respect to risk factors of recurrence (LA dilatation, years in AF, age, renal dysfunction, and other cardiovascular risk factors

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

    LAA occlusion should be considered to reduce the thromboembolic risk in patients with AF and a CHA2DS2VASc score ≥ 2 undergoing valve surgery

    Abbreviations: AF: Atrial fibrillation; LA: Left atrium; LAA: Left atrial appendage; NOAC:Non vitamin-K antagonist oral anticoagulant ; OAC:Oral anticoagulation; VKA: Vitamin-K antagonist


    The above table adopted from 2021 ESC Guideline[3]





    Q

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

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

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

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

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

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

    CABG : (Class IIa, Level of Evidence C)

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

    PCI : (Class IIa, Level of Evidence C)

    PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments
    PCI is recommended in patients undergoing transcatheter mitral valve intervention and coronary artery diameter stenosis > 70% in proximal segments

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


    The above table adopted from 2021 ESC Guideline[3]





    D

    Endocarditis prophylaxis

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

    ❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score

    VKA (Class I, Level of Evidence C):

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

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

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

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

    NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation

    Abbreviations: CAD: Coronary artery disease; VKA: Vitamin-K antagonist; AF: Artial fibrillation

    The above table adopted from 2020 AHA Guideline[2]

    Prophylaxis for rheumatic fever


    F

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

    ❑ Except those with rheumatic mitral stenosis, NOAC is recommended in patients with AF and VHD , or who received a bioprothesis valve > 3 months ago on the basis of CHA2DS2-VASc score

    VKA (Class I, Level of Evidence C):

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

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

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

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

    NOAC is not recommended in patients with mechanical valve with or without AF, and VKA should be continued for prevention of valve thrombosis formation

    Abbreviations: NOAC: Novel oral anticoagulant; VKA: Vitamin-K antagonist; AF: Artial fibrillation

    The above table adopted from 2020 AHA Guideline[2]

    F

    Median OperativeMortality Rates for Specific Surgical Procedures

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









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

    therapy not indicated

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






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





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

    Oxygen is recommended in hypoxic patients with SpO2<90% or PaO2 <60 mmHg
    Intubation is recommended in the presence of progressive respiratory failure in spite of oxygen administration or non-invasive ventilation

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

    ❑ In patients with respiratory distress (respiratory rate >25 breaths/min, SpO2<90%), non-invasive positive pressure ventilation is recommended to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation

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

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

    Diuretics : (Class IIa, Level of Evidence B)

    ❑ In patients with resistant edema who do not respond to an increase in loop diuretic doses, combination of a loop diuretic with thiazide type diuretic should be considered

    Vasodilators: (Class IIb, Level of Evidence B)

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

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

    Inotropic agents may be considered in patients with SBP <90 mmHg and evidence of hypoperfusion without response to fluid challenge, to improve [[peripheral perfusion]] and maintain end-organ function

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

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

    Vasopressors: (ClassIIb, Level of Evidence B)

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

    Anticoagulant therapy: (ClassI, Level of Evidence A)

    Thromboembolism prophylaxis such as LMWH is recommended in patients not already anticoagulated and no contraindication to anticoagulation, to prevent the risk of deep venous thrombosis and pulmonary embolism

    Opiates: (ClassIII, Level of Evidence C)

    Opiates is not routinely recommended, unless in selected patients with severe, intractable pain or anxiety

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

    The above table adopted from 2021 ESC Guideline

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

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

    1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M (August 2022). "2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". Eur Heart J. doi:10.1093/eurheartj/ehac262. PMID 36017572 Check |pmid= value (help).
    2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
    3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
     
     
     
     
     
     
     
     
     
     
     
    Stable chest pain suspected INOCA
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Non-invasive test more prevalent
    • Invasive test more comprehensive
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Invasive coronary functional testing
     
     
     
     
     
     
     
     
     
     
     
    Stress PET, Stress CMR, Stress echocardiography