Sandbox:Sara.Zand

Revision as of 03:46, 14 September 2022 by Sara Zand (talk | contribs) (→‎vt storm)
Jump to navigation Jump to search

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 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