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ACC/AHA Pocket Guideline

Based on the ACC/AHA 2006 Guideline Revision

Management of Patients With Valvular Disease

June 2006 Special thanks to

Distributed through support from Medtronic Heart Valves.

Medtronic Heart Valves was not involved in the development of this publication and in no way influenced its contents. Management of Patients With

June 2006

Writing Committee

Robert O. Bonow, MD, FACC, FAHA, Chair Blase A. Carabello, MD, FACC, FAHA Kanu Chatterjee, MD, FACC Antonio C. de Leon, Jr., MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA Michael D. Freed, MD, FACC, FAHA William H. Gaasch, MD, FACC, FAHA Bruce Whitney Lytle, MD, FACC Rick A. Nishimura, MD, FACC, FAHA Patrick T. O’Gara, MD, FACC, FAHA Robert A. O’Rourke, MD, MACC, FAHA Catherine M. Otto, MD, FACC, FAHA Pravin M. Shah, MD, MACC, FAHA Jack S. Shanewise, MD

i © 2006 American College of Foundation and the American Heart Association, Inc.

The following material was adapted from the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease (published in the August 1, 2006, issues of Journal of the American College of Cardiology and Circulation). For a copy of the full report or published executive summary, visit our Web sites at http://www.acc.org or http://www.americanheart.org or call the ACC Resource Center at 1-800-253-4636, ext. 694.

ii 2-D and Doppler Valve Surgery or Intervention Management of Prosthetic Valves 3 9 9 9 51 17 56 46 46 16 25 35 14 22 22 42 12 53 28 39 19 50 50 ......

...... Patients With Prosthetic Heart Valves Patients With Noncardiac Surgery/Dental Care Adequate Antithrombotic Therapy Doppler Echocardiography IV. Antithrombotic Antithrombotic Management IV. III. Indications for Valve Surgery Surgery Valve for Indications III. II. Indications for 2-D and Indications for 2-D and II. I. Introduction I. C. Excessive Anticoagulation C. Mitral Stenosis C. Aortic Regurgitation B. Embolic Events During F. Mitral Valve F. Antithrombotic Therapy in Patients Requiring D. G. Mitral Regurgitation B. Aortic Regurgitation E. Infective Selection Valve Major Criteria for F. E. Heart Valves of Prosthetic F. D. Bicuspid With Dilated Ascending Dilated Ascending With Valve Bicuspid Aortic D. E. Mitral Stenosis Mitral Regurgitation D. B. Contents of Prosthetic Heart Valves Heart of Prosthetic or Percutaneous Intervention or Percutaneous A. Indications for Anticoagulation in A. Aortic Stenosis A. Severity of Valve Disease Valve A. Severity of 2 I. Introduction

Valvular heart disease is one of several cardiac disorders that affect a large number of people who require diagnostic procedures and long-term management. The Pocket Guideline for Management of Patients With Valvular Heart Disease provides rapid prompts for 3 specific aspects of the management of patients with valvular heart disease. The pocket guide is derived from the full text of the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. These guidelines were first published in 1998 and then revised in 2006. The full-text guidelines provide a more detailed explanation of the management of valvular heart disease, along with appropriate caveats and levels of evidence. The executive summary of the guide- lines was published in the Journal of American College of Cardiology and Circulation. Both the full guidelines and the executive summary are available online, at http://www.acc.org or http://www.americanheart.org. Users of this pocket guide should consult those documents for additional information.

3 Scope of the Pocket Guide

The Guidelines for the Management of Patients With Valvular Heart Disease cannot be reproduced in their entirety in a pocket guide format. For this reason, the pocket guide focuses on the 3 aspects of management in the conditions that are most frequently encountered in the practice of adult cardiology:

■ Indications for echocardiography

■ Indications for valvular surgery or percutaneous intervention

■ Antithrombotic management of prosthetic heart valves

Classification of Recommendations

A classification of recommendation and a level of evidence have been assigned to each recommendation. Classifications of recom- mendations and levels of evidence are expressed in the American College of Cardiology/American Heart Association (ACC/AHA) format as follows and described in more detail in Figure 1:

Class I Conditions for which there is evidence for and/or general agreement that the procedure or treatment is beneficial, useful, and effective.

Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

4 Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb Usefulness/efficacy is less well established by evidence/opinion.

Class III Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

Level of In addition, the weight of evidence in support Evidence of the recommendation is listed as follows:

Level of Evidence A Data derived from multiple randomized clinical trials.

Level of Evidence B Data derived from a single randomized trial or nonrandomized studies.

Level of Evidence C Only consensus opinion of experts, case studies, or standard-of-care.

5 Figure 1. Applying Classification of Recommendations and Level of Evidence in ACC/AHA Format

SIZE OF TREATMENT EFFECT

CLASS I CLASS IIA Benefi t >>> Risk Benefi t >> Risk Procedure/Treatment Additional studies with SHOULD be performed/ focused objectives needed administered IT IS REASONABLE to per- form procedure/administer treatment

LEVEL A ■ Recommendation that ■ Recommendation in favor Multiple (3-5) population procedure or treatment of treatment or procedure risk strata evaluated* is useful/effective being useful/effective General consistency of ■ Suffi cient evidence from ■ Some confl icting evidence direction and magnitude multiple randomized trials from multiple randomized of effect or meta-analyses trials or meta-analyses

LEVEL B ■ Recommendation that ■ Recommendation in favor Limited (2-3) population procedure or treatment of treatment or procedure risk strata evaluated* is useful/effective being useful/effective ■ Limited evidence from ■ Some confl icting evidence single randomized trial or from single randomized trial nonrandomized studies or nonrandomized studies

LEVEL C ■ Recommendation that ■ Recommendation in favor Very limited (1-2) procedure or treatment is of treatment or procedure population risk strata useful/effective being useful/effective evaluated* ■ Only expert opinion, case ■ Only diverging expert studies, or standard-of-care opinion, case studies, or standard-of-care ESTIMATE OF CERTAINTY (PRECISION) OF TREATMENT EFFECT TREATMENT (PRECISION) OF OF CERTAINTY ESTIMATE Suggested phrases for should is reasonable writing recommendations† is recommended can be useful/effective/benefi cial is indicated is probably recommended is useful/effective/benefi cial or indicated

6 Class IIb Class III * Data available from clinical trials Benefi t ≥ Risk Risk ≥ Benefi t or registries about the usefulness/ efficacy in different subpopulations, Additional studies with broad No additional studies needed such as gender, age, history of objectives needed; additional Procedure/Treatment should , history of prior myo- registry data would be helpful NOT be performed/adminis- cardial infarction, history of heart Procedure/Treatment tered SINCE IT IS NOT HELP- failure, and prior aspirin use. A MAY BE CONSIDERED FUL AND MAY BE HARMFUL recommendation with Level of Evidence B or C does not imply ■ Recommendation’s ■ Recommendation that that the recommendation is weak. usefulness/effi cacy less procedure or treatment is Many important clinical questions well established not useful/effective and addressed in the guidelines do not lend themselves to clinical trials. ■ may be harmful Greater confl icting Even though randomized trials are evidence from multiple ■ Suffi cient evidence from not available, there may be a very randomized trials or multiple randomized trials clear clinical consensus that a meta-analyses or meta-analyses particular test or therapy is useful or effective. ■ Recommendation’s ■ Recommendation that † In 2003 the ACC/AHA Task Force on usefulness/effi cacy less procedure or treatment is Practice Guidelines recently provided well established not useful/effective and a list of suggested phrases to use when writing recommendations. ■ Greater confl icting may be harmful All recommendations in this ■ evidence from single Limited evidence from guideline have been written in full randomized trial or single randomized trial or sentences that express a complete nonrandomized studies nonrandomized studies thought, such that a recommenda- tion, even if separated and presented ■ Recommendation’s ■ Recommendation that apart from the rest of the document usefulness/effi cacy less procedure or treatment is (including headings above sets of recommendations), would still well established not useful/effective and convey the full intent of the recom- ■ Only diverging expert may be harmful mendation. It is hoped that this will opinion, case studies, or ■ Only expert opinion, case increase readers’ comprehension of standard-of-care studies, or standard-of-care the guidelines and will allow queries at the individual recommenda- tion level. may/might be considered is not recommended may/might be reasonable is not indicated usefulness/effectiveness is should not unknown/unclear/uncertain is not useful/effective/benefi cial or not well established may be harmful 7 The following abbreviations are used throughout this pocket guide:

AR aortic regurgitation

AS aortic stenosis

AVR aortic

BAV

CABG coronary artery bypass grafting

ECG electrocardiogram

EF ejection fraction

IE

INR international normalized ratio

LMWH low-molecular-weight heparin

LV left ventricular

MR mitral regurgitation

MRI magnetic resonance imaging

MS mitral stenosis

MV mitral valve

MVP

NYHA New York Heart Association

PMBV percutaneous mitral balloon valvotomy

RV right ventricular

TEE transesophageal echocardiography

TTE transthoracic echocardiography

TR tricuspid regurgitation

UFH unfractionated heparin

2-D 2-dimensional 8 2-D and Doppler Echocardiography 9 the basis the continued on page 12 continued (2-D) and Doppler (2-D) and Doppler be determined on be determined 2-dimensional 2-dimensional grade the severity of the valve lesion grade the severity of the (Level of Evidence: B) A. Diagnosis and assessment of AS severity. A. Diagnosis and assessment of AS severity. (Level of Evidence: B) and wall thickness, size, B. Assessment of LV function. Recommendations for Aortic Stenosis in Echocardiography . In certain situations, is required In certain situations, cardiac catheterization . 1. Echocardiography is recommended for the following: for further clarification of severity of the valve lesion. for further clarification (Table 1) (Table Class I a mean transvalvular pressure gradient, and derived valve area. a mean transvalvular pressure gradient, and Doppler criteria be used to to Doppler criteria be used peak velocity, echocardiographic measurements of a Doppler echocardiogram. The committee recommends that quantitative committee recommends that quantitative echocardiogram. The with Doppler the severity of the stenotic lesion can be defined presence of other associated valve disease. In most patients, presence of other associated (LV) size and function, the degree of hypertrophy, and the the degree of hypertrophy, size and function, (LV) presence of aortic stenosis (AS) and determining left ventricular (AS) and determining left ventricular presence of aortic stenosis The 2-D echocardiogram is valuable for confirming the The 2-D echocardiogram B. Aortic Stenosis B. of a detailed, comprehensive comprehensive of a detailed, The severity of valve disease can of valve disease can The severity A. Severity of Valve Disease Valve of Severity A. and Doppler Echocardiography and Doppler II. Indications for 2-D for 2-D Indications II. 2-D and Doppler Echocardiography 10 etvnrclrsz Increased Left ventricularsize Additional EssentialCriteria eugtn rcin() esta 0 04 Greater thanorequalto50 65%LVOT Greaterthanorequalto60 ofsevere AR 30-49 greaterthan 3-4+ Greater than0.6 mildbutnosigns Lessthan30 ofLVOT 30-59 Regurgitant orificearea(cm lessthan25% Regurgitant fraction(%) Lessthan30 0.3-0.6 Regurgitant volume(ml/beat) 2+ Lessthan0.3 Centraljet, width Quantitative (cathorecho) width (cm) Greaterthan Doppler venacontracta Centraljet, width 1+ Color Dopplerjetwidth Angiographic grade Greaterthan50 Qualitative Greater than 10 30-50 5-10 Valve Lessthan30 area(cm pressure (mmHg) Lessthan5 Pulmonary arterysystolic Greaterthan 4.0 Mean gradient(mmHg)* Greater than40 3.0-4.0 25-40 Lessthan3.0 Lessthan25 Valve area(cm Mean gradient(mmHg)* Jet velocity(m/s) Indicator A. Left-sidedvalvedisease Table 1. Valve areaindex(cm

ClassificationoftheSeverity Valve Diseasein Adults

2 2 Getrta . 1015 Lessthan1.0 1.0-1.5 Greaterthan1.5 ) Lessthan1.0 1.0-1.5 Greaterthan1.5 ) 2 /m 2 Lessthan0.6 ) 2 Ls hn01 01-.9 Greaterthanorequalto0.30 0.10-0.29 Lessthan0.10 )

Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe Aortic Regurgitation Aortic Stenosis Mitral Stenosis 2-D and Doppler Echocardiography 11 = left atrial/;

LA 2 Characteristic = echocardiography; mild greater than 0.7 cm with large central MR jet 2 Mitral Regurgitation Mitral echo = mitral regurgitation. MR Mild Moderate Severe Moderate Mild

= catheterization; ) Less than 0.20 0.2-0.39 Greater than or equal to 0.40 2 cath = left ventricular outflow tract; = aortic regurgitation; Regurgitant orifice area (cm Regurgitant fraction (%) Less than 30 30-49 Greater than or equal to 50 Regurgitant volume (ml/beat) Less than 30 30-59 or equal to 60 Greater than Quantitative (cath or echo) Doppler vena contracta width (cm) Less than 0.3 0.69 0.3 – or equal to 0.70 Greater than or less than 20% but no present, LA area) (area greater than 40% of LA criteria for jet area) or with a wall-impinging severe MR LA swirling in of any size, AR knowledge of or forward flow across the valve. Modified from the Journal of the American Society of for evaluation of the severity of native valvular regurgitation with Recommendations 16, Zoghbi WA, Echocardiography, 777–802, Copyright 2003, with permission from American Society two-dimensional and Doppler echocardiography, of Echocardiography. Severe pulmonic regurgitation: Severe pulmonic regurgitation: Color jet fills outflow tract Doppler signal with a steep deceleration slope Dense continuous wave Severe : Severe pulmonic stenosis: Jet velocity greater than 4 m/s or maximum gradient greater than 60 mm Hg Severe tricuspid regurgitation: Severe tricuspid regurgitation: contracta width greater than 0.7 cm and Vena Systolic flow reversal in hepatic veins Severe tricuspid stenosis: Severe tricuspid stenosis: area less than 1.0 cm Valve B. Right-sided Right-sided B. valve disease

Left ventricular size Enlarged Additional Essential Criteria Left atrial size Enlarged Color Doppler jet area Color Doppler jet area central jet Small, of MR Signs contracta width greater than Vena (less than 4 cm Angiographic grade Angiographic grade 1+ 2+ 3-4+ Qualitative LVOT *Valve gradients are flow dependent and when used as estimates of severity of valve stenosis should be assessed with *Valve 2-D and Doppler Echocardiography 12 examination; to assessthecauseofARandvalve morphology; regurgitation (AR) whenitisequivocalonthebasis ofphysical Echocardiography isindicatedtoconfirmthediagnosis ofaortic C.Regurgitation Aortic or cardiaccatheterizationlaboratories. studies canbeperformedinexperienced echocardiographic whether stenosisissevereoronly moderateinseverity. Such (i.e., dobutamineinfusion)stress,withthegoalofdetermining state andagainduringexerciseorlow-dosepharmacological pressure gradientandtocalculatevalveareaduringabaseline dysfunction, itmaybeusefultodeterminethetransvalvular In selectedpatientswithlow-flow/low-gradientASandLV Class IIa 1.Dobutaminestressechocardiographyis AS duringpregnancy. severity andLV functioninpatientswithknown D. Assessmentofchangesinhemodynamic changing symptomsorsigns. C. Re-evaluationofpatientswithknownASand (Level ofEvidence:B) flow/low-gradient ASandLV dysfunction. reasonable toevaluatepatientswithlow- (Level ofEvidence:B) for moderateAS;every3to5yearsmildAS. patients everyyearforsevereAS;1to2years recommended forre-evaluationofasymptomatic 2. Transthoracic echocardiography(TTE)is (Level ofEvidence:B) (Level ofEvidence:B) 2-D and Doppler Echocardiography 13 (Level of Evidence: B) (Level of Evidence: B) (Level of Evidence: B) E. Re-evaluation of mild, moderate, or E. Re-evaluation of mild, moderate, severe AR in patients with new or changing symptoms. C. Assessment of AR and severity of aortic C. Assessment of AR and severity of aortic dilatation in patients with enlarged aortic roots. (Level of Evidence: B) size and function LV Re-evaluation of D. in asymptomatic patients with severe AR. (Level of Evidence: B) A. Diagnosis and assessment of severity of acute A. Diagnosis and assessment or chronic AR. cause of chronic AR B. Assessment of the and aortic root (including valve morphology and assessment of size and morphology) volume), and dimension (or hypertrophy, LV systolic function. for the following: 1. Echocardiography is indicated Class I Aortic Regurgitation in Echocardiography Recommendations for size. to assess aortic root function; and Recommendations overload, which includes LV dimension, mass, and systolic mass, and systolic dimension, includes LV which overload, regurgitation; to assess the ventricular response to volume response to volume to assess the ventricular regurgitation; to provide a semiquantitative estimate of the severity of severity of the estimate a semiquantitative to provide 2-D and Doppler Echocardiography 14 the primaryimaging techniqueforidentifyingand following to theseverityand rateofdilatation.Echocardiography remains with time, andthereisa risk ofaorticdissectionthatisrelated or AR.Aorticrootascending aortic dilatationcanprogress aorta evenintheabsenceofhemodynamically significantAS which mayresultindilatationof theaorticrootorascending aortic valves(BAV) havedisorders ofvascularconnectivetissue, There isgrowingawareness thatmanypatientswithbicuspid D.Bicuspid AorticValveDilated AscendingAorta With LV dilatation. are clinicalfindingsthatsuggestworseningARorprogressive of changingsymptomsorexercisetolerance, orwhenthere at theonsetofsymptoms,whenthereisanequivocalhistory or function.Repeatechocardiogramsarealsorecommended serial studieshaverevealedprogressivechangesinLV size LV dilatation,levelofsystolicfunction,andwhetherprevious noninvasive testing dependsontheseverityofAR,degree established, thefrequencyofclinicalre-evaluationandrepeat Once thechronicityandstabilityofprocesshavebeen with ahistoryofequivocalsymptoms. functional capacityandsymptomaticresponseinpatients the aorta.Exercisetestingisreasonableforassessmentof tomography maybeusefultofurtherevaluatethesizeof unsatisfactory echocardiograms.MRIandcardiaccomputed the volumeoverload, andtheyareusefulinpatientswith (MRI) canalsobeusedtoassesstheventricularresponse Radionuclide angiographyandmagneticresonanceimaging 2-D and Doppler Echocardiography 15 stature of either gender. (Level of Evidence: C) (Level of Evidence: C) and dilatation of the aortic 3. Patients with BAV root or (diameter greater than of aortic 4.0 cm*) should undergo serial evaluation by root/ascending aorta size and morphology cardiac magnetic resonance, echocardiography, or computed tomography on a yearly basis. initial transthoracic echocardiogram to assess initial transthoracic echocardiogram root and ascending aorta. diameter of the aortic (Level of Evidence: B) computed tomography 2. Cardiac MRI or cardiac when morph- with BAV is indicated in patients or ascending aorta cannot ology of the aortic root by echocardiography. be assessed accurately Consider lower threshold values for patients of small Consider lower threshold values for patients of small * an should undergo 1. Patients with known BAV Class I Aorta Ascending and Dilated Valve Aortic Bicuspid With in Patients (or Other Imaging Modalities) Recommendations for Echocardiography Echocardiography for MRI or computed tomography. with cardiac Recommendations assessment of the degree of enlargement, can be obtained can be obtained of the degree of enlargement, assessment of the aortic root and ascending aorta, as well as full aorta, as well as full root and ascending of the aortic these patients. More accurate quantification of the diameter diameter of the quantification accurate patients. More these 2-D and Doppler Echocardiography 16 Echocardiography inMitral Stenosis Class I Recommendations Doppler recordingsoftransmitralandtricuspidvelocities. done usingeitherasupinebicycleoranuprighttreadmillwith for (MR) orAR.Formalhemodynamicexercisetestingcanbe signal, andassessesseverityofconcomitantmitralregurgitation systolic pressurefromthetricuspidregurgitation(TR)velocity hemodynamic severityofMS, estimatespulmonaryartery type ofintervention.Dopplerechocardiographyassessesthe These featuresareimportantinconsideringthetimingand leaflet calcification,andsubvalvularcommissuralfusion. mitral valve(MV),includingleafletmobility, leafletthickness, with mitralstenosis(MS)toassessthemorphologyof Two-dimensional echocardiography shouldbeusedinpatients E. Mitral Stenosis 1.Echocardiographyisindicatedforthefollowing: symptoms, andsigns. echocardiographic findings,clinical there isadiscrepancy betweenrestingDoppler by exerciseDoppler echocardiographywhen C. Assessmentofthehemodynamic response changing symptomsorsigns. B. Re-evaluationinpatientswith knownMSand valvotomy [PMBV]). suitability forpercutaneousmitral balloon assessment ofvalvemorphology(todetermine assessment ofconcomitantvalvularlesions,and A. DiagnosisofMS, assessmentofseverity, (Level ofEvidence:B) (Level ofEvidence: C) (Level ofEvidence:B) 2-D and Doppler Echocardiography 17 (Level of Evidence: C) (Level of Evidence: C) (Level of Evidence: C) for routine evaluation of MV morphology and when complete TTE data are satisfactory. re-evaluation of asymptomatic patients with re-evaluation of asymptomatic findings to assess MS and stable clinical (for those with pressure every every year; moderate MS, severe MS, every 3 to 5 years). MS, 1 to 2 years; and mild (Level of Evidence: C) (Level of Evidence: morphology and hemo- B. Assessment of MV when TTE provides dynamics in patients suboptimal data. 2. Transesophageal echocardiography (TEE) echocardiography 2. Transesophageal for the following: is indicated of left of presence or absence A. Assessment of severity and assessment atrial thrombus PMBV. considered for of MR in patients in the 1. Echocardiography is reasonable in patients with MS 1. TEE is not indicated 1 or both mitral leaflets in the parasternal long-axis view, long-axis view, 1 or both mitral leaflets in the parasternal (MVP). On 2-D echocardiography, systolic displacement of systolic displacement (MVP). On 2-D echocardiography, the most useful noninvasive test for defining MV prolapse the most useful noninvasive Two-dimensional and Doppler echocardiography constitutes Two-dimensional F. Mitral Valve Prolapse Valve Mitral F. Class III Class IIa 2-D and Doppler Echocardiography 18 Class III Class IIa in Asymptomatic Mitral Valve Prolapse Class I Recommendations redundancy, annulardilatation,andchordalelongation. include structuralchangessuchasleafletthickening, for than 5mm.TheechocardiographiccriteriaforMVPshould MVP isevenmorecertainwhenleafletthicknessgreater plane, indicatesahighlikelihoodofMVP. Thediagnosisof Echocardiography particularly whentheycoaptontheatrialsideofannular 1.Echocardiographyisindicatedforthediagnosisof 1.Echocardiography isnotindicatedtoexclude 1.Echocardiographycanbeeffectivefor (Level ofEvidence: B) tive ofMVPora positivefamilyhistory. of clinicalsymptoms orphysicalfindingssugges- symptoms intheabsenceofaconstellation MVP inasymptomaticpatientswith ill-defined (Level ofEvidence:C) with physicalsignsofMVPorknownMVP. B. Riskstratificationinasymptomaticpatients to supportthediagnosis. have beendiagnosedwithoutclinicalevidence A. ExcludingMVPinasymptomaticpatientswho with physicalsignsofMVP. ventricular compensationinasymptomaticpatients MVP andassessmentofMR,leafletmorphology, and (Level ofEvidence:C) (Level ofEvidence:B) 2-D and Doppler Echocardiography 19 in any patient suspected of having (Level of Evidence: C) (Table 1) (Table MR. A. Baseline evaluation of LV size and function, A. Baseline evaluation of LV left atrial size, and right ventricular (RV) and severity of pulmonary artery pressure, MR B. Delineation of the mechanism of MR. (Level of Evidence: B) (Level of Evidence: C) (Level of Evidence: 2. Routine repetition of echocardiography is of echocardiography repetition 2. Routine patient for the asymptomatic not indicated and mild MR and no MR or MVP who has MVP or symptoms. in clinical signs with no changes 1. TTE is indicated for the following: Class I in Mitral Regurgitation Mitral of successful MV repair. for determining the feasibility in Recommendations for Echocardiography Echocardiography for anatomic cause of MR, which is important may also identify the Recommendations size and pulmonary artery systolic pressure. Echocardiography size and pulmonary artery ejection fraction [EF] and end-systolic dimension), left atrial ejection fraction [EF] to (including LV size and systolic function (including LV to volume overload should be used to assess the severity of MR, the LV response the severity of MR, the LV should be used to assess pensable in the management of patients with MR and pensable in the management Two-dimensional and Doppler echocardiography is indis- and Doppler Two-dimensional G. Mitral Regurgitation Mitral G. 2-D and Doppler Echocardiography Echocardiography inMitral Regurgitation Class I Recommendations for Class III Transesophageal Class IIa 20 1.PreoperativeorintraoperativeTEEis indicated 1.TTEisnotindicatedforroutinefollow-up 1.ExerciseDopplerechocardiographyisreasonable moderate tosevereMR. dimension) inasymptomaticpatientswith function (estimatedbyEFandend-systolic C. AnnualorsemiannualsurveillanceofLV to assessfeasibility ofrepairandtoguide to establishthe anatomic basisforsevereMR (Level ofEvidence:C) MR andnormalLV sizeandsystolicfunction. evaluation ofasymptomaticpatientswithmild (Level ofEvidence:C) pulmonary arterypressureandMRseverity. exercise toleranceandtheeffectsofon in asymptomaticpatientswithsevereMRtoassess replacement orMVrepair. hemodynamics intheinitialevaluationafterMV E. AssessmentofLV sizeandfunctionMV (Level ofEvidence:C) function afterachangeinsignsorsymptoms. D. AssessmentoftheMVapparatusandLV (Level ofEvidence:C) (Level ofEvidence:C) 2-D and Doppler Echocardiography 21 (Level of Evidence: C) (Level of Evidence: B) (Level of Evidence: (Level of Evidence: C) patients with or surveillance of asymptomatic native valve MR. patients with severe MR who are considered patients with severe MR feasibility of repair. for surgery to assess in patients in whom surgery is recommended. is recommended. surgery in whom in patients B) (Level of Evidence: of MR when for evaluation 2. TEE is indicated regarding information nondiagnostic TTE provides and/or status MR, mechanism of MR, severity of function. of LV asymptomatic 1. Preoperative TEE is reasonable in 1. TEE is not indicated for routine follow-up asymptomatic LV dysfunction. asymptomatic LV every 6 to 12 months to assess symptoms or transition to every 6 to 12 months to assess symptoms be monitored with clinical evaluation and echocardiography be monitored with clinical evaluation and should be performed yearly. Patients with severe MR should should be performed yearly. moderate MR, clinical evaluations and echocardiograms moderate MR, clinical evaluations and echocardiograms evidence that regurgitation has worsened. In patients with evidence that regurgitation has worsened. echocardiograms are not necessary unless there is clinical echocardiograms are not necessary unless can be monitored clinically on a yearly basis, but yearly can be monitored clinically on a yearly basis, LV enlargement or dysfunction or pulmonary enlargement or dysfunction or pulmonary LV Asymptomatic patients with mild MR and no evidence of Asymptomatic patients with mild MR and no Class III Class IIa Valve Surgery or Intervention Class IIa Valve Replacementin Aortic Stenosis Class I Recommendations for symptomatic patientswithsevereAS Aortic Aortic valvereplacement(AVR) isclearlyindicatedin A.Stenosis Aortic or Percutaneous Intervention III. Indicationsfor Valve Surgery asymptomatic patientswithsevereAS. surgery. Managementdecisionsaremorecontroversial in another cardiacoperationshouldundergoAVR atthetimeof moderate orsevereAS, evenwithoutsymptoms,whoundergo 22 1.AVR isindicatedforthefollowingpatients: 1.AVR isreasonableforpatients withmoderate or otherheartvalves. AS C. PatientswithsevereAS B. PatientswithsevereAS (Level ofEvidence:B) A. SymptomaticpatientswithsevereAS. dysfunction (EFlessthan0.50). valves. the aorta,orreplacementrepairofotherheart artery bypassgraftsurgery(CABG),on † undergoingCABG orsurgeryontheaorta (Level ofEvidence:C) (Level ofEvidence: B) † † (Figure 2) andLV systolic undergoingcoronary (Level ofEvidence:C) . Patientswith †

Valve Surgery or Intervention 23 No Normal No fraction LV ejection ejection LV = left ventricular; LV Reevaluation rapid progression, and/or Severe valve calcification, expected delays in surgery Clinical follow-up, patient education, Normal risk factor modification, annual echo 2 Yes Less than 0.50 Equivocal Symptoms? = coronary artery bypass graft surgery; Exercise test Class IIb AVA less than 1.0 cm less than 1.0 AVA Severe Aortic Stenosis CABG Vmax greater than 4 m/s Vmax greater than 4 Mean gradient > 40 mm Hg Mean gradient > 40 Class I BP ↓ Symptoms

= blood pressure; Class IIb BP Aortic Replacement Valve Yes Management Strategy Strategy Management Class I Preoperative coronaryPreoperative angiography Class I = maximal velocity across aortic valve by Doppler echocardiography. Undergoing = aortic valve area; CABG or other for Patients With Severe Aortic Stenosis With Severe for Patients Figure 2. Figure heart surgery? Vmax AVA Preoperative coronaryPreoperative as determined angiography should be performed coronary by age, symptoms, and routinely, there is discordance between clinical risk factors. Cardiac catheterization and angiography may also be helpful when aorticfindings and echocardiography (echo). Modified from Otto CM. Valvular and timing stenosis: disease severity of intervention. J Am Coll Cardiol 2006;47:2141–51. Valve Surgery or Intervention Class III Class IIb 24 1.AVR isnotusefulforthe prevention ofsudden 1.AVR maybeconsideredforthefollowingpatients: of symptomsorasymptomatichypotension). abnormal responsetoexercise(e.g.,development onset. surgery mightbedelayedatthetimeofsymptom calcification, andcoronaryarterydisease)orif is ahighlikelihoodofrapidprogression(age, † recommendations. none ofthefindingslistedunder theClassIIa/IIb death inasymptomaticpatients with ASwhohave severe AS(aorticvalvearealessthan0.6cm D. Asymptomaticpatientswithextremely C. PatientsundergoingCABGwhohavemildAS B. AdultswithsevereasymptomaticAS (Level ofEvidence:C) A. AsymptomaticpatientswithsevereAS be rapid. severe valvecalcification,thatprogressionmay when thereisevidence, suchasmoderateto or less. when theexpectedoperativemortalityis1.0% jet velocitygreaterthan5.0mpersecond) mean gradientgreaterthan60mmHg,and Objective definition ofvalveseverityisprovided inTable 1. (LevelofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:B) † ifthere † and 2 , †

Valve Surgery or Intervention 25 . Patients with BAV may have may have BAV . Patients with (Level of Evidence: C) (Figure 3) (Level of Evidence: B) 2. Surgery to repair the aortic root or replace 2. Surgery to repair the aortic root or replace with the ascending aorta is indicated in patients if the diameter of the aortic root or ascending BAV of aorta is greater than 5.0 cm* or if the rate increase in diameter is 0.5 cm per year or more. (Level of Evidence: C) (Level of Evidence: B) B. Asymptomatic patients with chronic severe dysfunction (EF 0.50 or less) systolic AR and LV at rest. C. Patients with chronic severe AR while under- going CABG or surgery on the aorta or other heart valves. A. Symptomatic patients with severe A. Symptomatic patients systolic function. AR irrespective of LV following patients: is indicated for the 1. AVR the aorta. ascending aorta may be indicated depending on the size of ascending aorta may dilated ; surgery to repair the aortic root or replace the the aortic root or replace surgery to repair dilated aortas; Class I Aortic Regurgitation Severe in Chronic Recommendations for Valve Aortic for Recommendations dilated aortic roots dilated aortic systolic dysfunction at rest, marked LV dilatation, or severely dilatation, LV at rest, marked systolic dysfunction cardiac symptoms and for asymptomatic patients with LV LV patients with and for asymptomatic cardiac symptoms AVR is indicated for patients with chronic severe AR who have chronic severe AR for patients with is indicated AVR B. Aortic Aortic Regurgitation B. Valve Surgery or Intervention echocardiography. may “Stable”refers tostableechocardiographicmeasurements.Insomecenters,serialfollow-up eval AVR Cardiac catheterizationandangiographymayalsobehelpful whenthereisdiscordancebetweenclinicalfindingsand SD be performed withRVG orMRIratherthanechocardiography toassessLVbe performed volumeandsystolicfunction. With Chronic Severe Aortic Regurgitation Figure 3. 26 =end-systolicdimension. Reevaluation =evalutation; = aortic valvereplacement; =aortic every 6-12mo every Clinical eval Echo every Echo every 12 mo Yes D<45mmor SD D<60mm DD ManagementStrategy forPatients Stable? Normal EF Normal LV = left ventricular; ventricular; =left initial study Reevaluate andEcho No, or 3 mo No DD Chronic Severe Aortic Regurgitation Chronic SevereAortic =end-diastolicdimension; Clinical eval every 6mo every Echo every Echo every EF borderlineoruncertain SD 45-50mmor MRI DD 60-70mm 12 mo Clinical eval+Echo Yes =magneticresonanceimaging; No symptoms LV dimensions? Stable? Exercise test LV function? Symptoms? RVG orMRI Equivocal initial study Reevaluate andEcho No, or 3 mo Echo Stable? =echocardiography; Symptoms EF of50%orless Yes Clinical eval every 6mo every Echo every Echo every 6 mo D>55mmor SD RVG SD 50-55mmor Yes D>75mm DD DD 70-75mm =radionuclideventriculography; Class I EF Consider hemodynamic Class I =ejectionfraction; response toexercise Class IIa Class I AVR Class IIb Abnormal Normal Valve Surgery or Intervention 27 (Level of Evidence: C) (Level of Evidence: (Level of Evidence: C) A. Patients with moderate AR while undergoing A. Patients with moderate CABG or surgery on the ascending aorta. (Level of Evidence: C) B. Asymptomatic patients with severe AR and function at rest (EF greater systolic normal LV dilatation than 0.50) when the degree of LV mm exceeds an end-diastolic dimension of 70 there or end-systolic dimension of 50 mm, when dilatation, declining is evidence of progressive LV or abnormal hemodynamic exercise tolerance, responses to exercise.* (Level of Evidence: B) with severe AR with normal LV systolic function LV with severe AR with normal dilatation but with severe LV (EF greater than 0.50) greater than 75 mm or (end-diastolic dimension greater than 55 mm).* end-systolic dimension 3. In patients with BAV undergoing AVR because because AVR undergoing BAV with 3. In patients 3.1.7. and 3.2.3.8. or AR (see Sections of severe AS of the aortic root guidelines), repair in the full-text aorta is indicated of the ascending or replacement or ascending aorta of the aortic root if the diameter 4.5 cm.* is greater than may be considered in the following patients: 1. AVR patients is reasonable for asymptomatic 1. AVR Class IIb Class IIa Valve Surgery or Intervention intervention shouldbeconsidered. MS independentofthecalculated valvearea,andfurther (25 mmHg)withexertionhave hemodynamically significant (greater than15mmHg),orpulmonary arterywedgepressure pressure (greaterthan60mmHg), meantransmitralgradient symptomatic withasignificantelevationofpulmonaryartery to MSfromthosedueothercauses.Patientswhoare noninvasive) maybeusefultodifferentiatesymptomsdue formal exercisetestingwithhemodynamics(invasive or a discrepancybetweensymptomsandhemodynamicdata, the feasibilityofperformingPMBV symptoms, pulmonaryarterypressure, RV function,and Indications forinterventioninpatientswithMSdependon C. Mitral Stenosis Class III 28 1.AVR isnotindicatedforasymptomaticpatients *Consider lowerthresholdvaluesforpatientsofsmall stature ofeithergender. (Level ofEvidence:B) end-systolic dimensionlessthan50mm).* severe (end-diastolicdimensionlessthan70mm, when thedegreeofdilatationisnotmoderateor LV systolicfunctionatrest(EFgreaterthan0.50) with mild,moderate, orsevereARandnormal (Figures 4-6) . Ifthereis Valve Surgery or Intervention 29 PMBV Consider 3+ to 4+ MR Exclude LA clot, = left atrial; LA ‡ Class IIb Yes Class I ) and severe pulmonary Class I 2 Symptomatic (see Figures 5 and 6) = echocardiography; Yes Yes echo PASP > 50 mm Hg? > 50 PASP

2 Yes 25 mm Hg No ≥ 1.5 cm Exercise ≤ Symptoms? Mitral Stenosis = electrocardiogram; MVA MVA Mild stenosis or or PAWP or PAWP or PASP > 60 mm Hg or PASP severe stenosis* Poor exercise tolerance Poor Valve morphology Valve ECG favorable for PMBV? No † History, physical exam CXR, ECG, 2D echo/Doppler exam CXR, physical History, = 2-dimensional. No New onset AF? = chest X-ray; = chest X-ray; 2D Asymptomatic CXR

2 Management Strategy for Patients With Mitral Stenosis Mitral With for Patients Strategy Management No Yearly Yearly History, History, follow-up CXR, ECG CXR, Mild stenosis = mitral regurgitation; physical exam, MVA>1.5 cm = atrial ; Figure 4. Figure hypertension (pulmonary artery mitral balloon valvotomy pressure > 60 mm Hg) should undergo percutaneous failure. or mitral valve replacement to prevent right ventricular (PMBV) AF MR and that the mean transmitral gradients, pulmonary artery and pulmonary artery wedge pressure (PAWP), systolic should also be taken into consideration. pressure (PASP)

*The writing committee recognizes that there may be variability in the measurement of mitral valve area (MVA) (MVA) of mitral valve area *The writing committee recognizes that there may be variability in the measurement ‡ Assuming no other cause for is present. † There is controversy as to whether patients with severe mitral stenosis (MVA < 1.0 cm (MVA † There is controversy as to whether patients with severe mitral stenosis Valve Surgery or Intervention † Thereiscontroversyastowhetherpatientswithsevere mitral stenosis (MVA <1.0cm *The writingcommitteerecognizesthattheremaybevariability inthemeasurementofmitralvalvearea (MVA) MVG CXR replacement (MVR)toprevent rightventricularfailure. (PH; PASP >60mmHg)shouldundergopercutaneousmitralballoonvalvotomy(PMBV)hypertension ormitralvalve pressure (PASP) shouldalsobetakenintoconsideration. systolic wedgepressure(PAWP), artery andpulmonary artery and thatthemeantransmitralgradients,pulmonary 30 follow-up With Mitral StenosisandMildSymptoms Figure 5. Yearly =chestX-ray; =meanmitralvalvepressure gradient; No PAWP PASP >60mmHg MVG >15mmHg MVA >1.5cm Mild stenosis ManagementStrategy forPatients Exercise ECG ≥ 25mmHg =electrocardiogram; follow-up 6 month History, physicalexam,CXR, ECG,2Decho/Doppler No 2 * favorable forPMBV? Valve morphology Symptomatic MitralStenosis Yes NYHA Functional ClassII PAP echo = pulmonary artery pressure; artery =pulmonary Class IIb Consider PMBV Exclude LA clot, Exclude LA 3+ to4+MR =echocardiography; Yes Class I Yes LA favorable forPMBV? MVA Valve morphology = left atrial; =left severe stenosis commissurotomy Moderate or 2D Consider ≤ or MVR Class IIa =2-dimensional. 1.5cm Yes 2 ) and severe pulmonary ) andseverepulmonary PAP >60mmHg † MR 2 * Severe PH =mitralregurgitation; No follow-up 6 month No Valve Surgery or Intervention 31 Yes Class I

2* 3+ to 4+ MR Consider PMBV Exclude LA clot, = mitral regurgitation; MR 1.5 cm ≤ = New York Heart Association; = New York Moderate or severe stenosis MVA MVA Valve morphology Valve favorable for PMBV? Class IIa NYHA = left atrial; LA Yes † No . High-risk Class IIb = echocardiography; surgical candidate? † (see text) = mitral valve replacement; No repair Class I echo or MVR MVR NYHA Functional Class III-IV NYHA Functional Yes Mitral valve Symptomatic Mitral Stenosis Symptomatic Mitral 2 History, physical exam, CXR, ECG, 2D echo/Doppler CXR, physical exam, History, 25 mm Hg ≥ = electrocardiogram; Exercise Mild stenosis MVA >1.5 cm MVA ECG MVG >15 mm Hg PASP >60 mm Hg >60 mm PASP PAWP PAWP Management Strategy for Patients with with for Patients Strategy Management No other Look for etiologies = mean mitral valve pressure gradient; = chest X-ray; = chest X-ray; Figure 6. Figure Symptoms Severe to Moderate and Stenosis Mitral = 2-dimensional. and that the mean transmitral gradients, pulmonary artery and pulmonary artery wedge pressure (PAWP), systolic should also be taken into consideration. pressure (PASP) rather than mitral valve surgeryvalvotomy (PMBV) CXR MVG 2D *The writing committee recognizes that there may be variability in the measurement of mitral valve area (MVA) (MVA) of mitral valve area *The writing committee recognizes that there may be variability in the measurement † It is controversial as to which patients with less favorable valve morphology should undergo percutaneous mitral balloon † It is controversial as to which patients with less favorable valve morphology Valve Surgery or Intervention Class IIb Class IIa Mitral Balloon Valvotomy forMitral Stenosis Class I Recommendations forPercutaneous 32 1.PMBVisindicatedforthefollowingpatientswith 1.PMBVisreasonableforpatientswithmoderate 1.PMBVmaybeconsideredforthefollowing candidates forsurgeryorareathighrisksurgery. are inNYHAfunctionalclassIII-IV, andareeithernot class II,III,orIV). A. Symptomaticpatients(NYHAfunctional thrombus ormoderatetosevereMR: favorable forPMBVintheabsenceofleftatrial (Level ofEvidence: C) severe MS A. Asymptomaticpatientswithmoderate or or moderatetosevereMR: patients intheabsenceofleftatrial thrombus (Level ofEvidence:C) or severeMS 60 mmHgwithexercise). greater than50mmHgatrestor hypertension (pulmonaryarterysystolicpressure B. Asymptomaticpatientswhohavepulmonary moderate orsevereMS PMBV whohavenewonsetofatrial fibrillation. † andvalvemorphologyfavorable for † whohaveanonpliablecalcifiedvalve, (Level ofEvidence:A) † andvalvemorphology (Level ofEvidence:C) Valve Surgery or Intervention 33 if 2 and with acceptable † operative risk when (1) PMBV is unavailable, operative risk when (1) PMBV is unavailable, atrial (2) PMBV is contraindicated because of left thrombus despite anticoagulation or because there is evidence of hemodynamically significant of hemodynamically there is evidence pressure pulmonary artery systolic MS based on artery wedge 60 mm Hg, pulmonary greater than or mean MV 25 mm Hg or more, pressure of during exercise. than 15 mm Hg gradient greater patients with symptomatic (NYHA functional class patients with symptomatic (NYHA functional III-IV) moderate or severe MS (Level of Evidence: C) (Level of Evidence: C) (Level of Evidence: C) performed in patients 2. PMBV should not be MR or left atrial thrombus. with moderate to severe (Level of Evidence: C) or severe MS who have C. Patients with moderate valve and are in NYHA a nonpliable calcified to surgery. as an alternative functional class III-IV, B. Symptomatic patients (NYHA functional class II, class functional patients (NYHA B. Symptomatic 1.5 cm MV area greater than III, or IV) with mild MS. 1. PMBV is not indicated for patients with 1. MV surgery (repair if possible) is indicated in Class I (Valve Repair or Replacement) or Repair (Valve Stenosis for Mitral Indications for Surgery Class III Management of Prostheic Valves Valve Surgery or Intervention Class III Class IIb Class IIa 34 1.MVrepairforMS isnotindicatedforpatients 1.MVreplacementisreasonableforpatientswith 1.MVrepairmaybe consideredforasymptomatic (Level ofEvidence:C) possible atthetimeofsurgery. receive MVreplacement,unlessrepairis PMBV. or (3)thevalvemorphologyisnotfavorablefor concomitant moderatetosevereMRispresent, † (Level ofEvidence: C) open commissurotomy isthepreferredapproach. performed inpatientsundergoing MVrepair; 2. Closedcommissurotomyshould notbe with mildMS. patients withmoderateorsevereMS severe MS MS 2. Symptomaticpatientswithmoderatetosevere PMBV orsurgicalMVrepair. symptoms whoarenotconsideredcandidatesfor 60 mmHg)withNYHAfunctionalclassI-II (pulmonary arterysystolicpressuregreaterthan morphology favorableforrepair. adequate anticoagulationandwhohavevalve had recurrentemboliceventswhilereceiving Objective definition ofvalveseverity isprovided inTable 1. † whoalsohavemoderatetosevereMRshould (Level ofEvidence:B) † andseverepulmonaryhypertension (Level ofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:C)

† whohave Valve Surgery or Intervention 35 . In most situations, . In most situations, (Figure 7) repair because of their demonstrated expertise in this area. repair because of their demonstrated expertise centers in which there is a high likelihood of successful MV centers in which there is a high likelihood However, this “early” operation should only be performed at However, surgery to prevent irreversible LV dysfunction from occurring. dysfunction surgery to prevent irreversible LV and the operative risk is low, it is reasonable to proceed with it is reasonable to proceed and the operative risk is low, If MV repair can be performed with a high degree of success If MV repair can be performed asymptomatic patient with severe MR and normal LV function. with severe MR and normal LV asymptomatic patient There is controversy regarding the timing of surgery in the regarding the timing There is controversy undergo surgery if chordal preservation is likely. undergo surgery if chordal dimension greater than 55 mm) poses a higher risk but may dimension greater than severe LV dysfunction (EF less than 0.30 and/or end-systolic dysfunction severe LV 0.60 and end-systolic dimension 40 to 55 mm). The patient with dimension 40 to 55 mm). The patient with 0.60 and end-systolic who demonstrate mild to moderate LV dysfunction (EF 0.30 to to moderate LV who demonstrate mild symptoms. Operation is also indicated in asymptomatic patients is also indicated in asymptomatic patients symptoms. Operation Operation is indicated for most patients with severe MR and any for most patients with severe MR and any Operation is indicated suitable MV anatomy. suitable MV MV repair is the operation of choice for those patients with for those patients is the operation of choice MV repair and pulmonary hypertension and pulmonary symptoms, LV EF, LV end-systolic dimension, , end-systolic dimension, LV EF, LV symptoms, Factors influencing the timing of surgery for MR include surgery for MR include the timing of Factors influencing D. Mitral Regurgitation Mitral D. Valve Surgery or Intervention 36 *Mitral valve (MV) repair may be performed in asymptomatic patients with normal left ventricular(LV) left inasymptomaticpatientswithnormal function *Mitral valve(MV)repairmay beperformed HT AF byanexperienced surgicalteamandthelikelihoodofsuccessfulMVrepair is greaterthan90%. if performed Reevaluation With Chronic Severe Mitral Regurgitation Figure 7. =atrialfibrillation; = hypertension; =hypertension; MV repairlikely?* New onsetAF? Pulmonary HT? Pulmonary Clinical eval Echo every Normal LVNormal EF >0.60 ESD <40 function 6 mos 6 mos every No No ManagementStrategy forPatients MV Echo =mitralvalve; Yes* Yes LV function? =echocardiography; No Class IIa Class IIa LV dysfunction ESD MVR Chronic SevereMitralRegurgitation EF and/or ≥ Class I ≤ =mitralvalvereplacement.

Clinical evaluation+Echo 40 mm 0.60 EF If notpossible, =ejectionfraction; Symptoms? MV repair MV repair MVR ESD EF >0.30 Class I ≤ 55mm ESD Class IIa =end-systolicdimension; LV function? Yes Chordal preservation Yes Medical therapy ESD >55mm EF <0.30 and/or likely? No Valve Surgery or Intervention 37

† and NYHA † (Level of Evidence: C) who require surgery, and patients should who require surgery, and mild to moderate LV dysfunction, LV and mild to moderate † † (Level of Evidence: B) MV replacement 2. MV repair is recommended over chronic (MVR) in the majority of patients with severe MR (Level of Evidence: B) with chronic severe C. Asymptomatic patients MR patients: with acute severe MR. A. Symptomatic patients (Level of Evidence: B) severe MR B. Patients with chronic be referred to surgical centers experienced in MV be referred to surgical centers experienced repair. EF 0.30 to 0.60, and/or end-systolic dimension EF 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. functional class II, III, or IV symptoms in the functional class II, III, dysfunction (severe LV absence of severe LV as EF less than 0.30 and/ dysfunction is defined greater than 55 mm). or end-systolic dimension the following for 1. MV surgery is recommended Class I Severe Mitral Regurgitation Mitral Severe Valve Surgery in Nonischemic in Surgery Valve Recommendations for Mitral Valve Surgery or Intervention Class IIb Class IIa 38 1.MVrepairisreasonableinexperiencedsurgical 1.MVrepairmaybeconsideredforpatientswith without residualMRisgreaterthan90%. 40 mm)inwhomthelikelihoodofsuccessfulrepair than 0.60andend-systolicdimensionless in whomMVrepairishighlylikely. or end-systolicdimensiongreaterthan55mm) severe LV dysfunction (EFlessthan0.30and/ NYHA functionalclassIII-IVsymptoms,and primary abnormalityofthemitralapparatus, exercise). 50 mmHgatrestorgreaterthan60with (pulmonary arterysystolicpressuregreaterthan of atrialfibrillationor(2)pulmonaryhypertension chronic severesecondaryMR (Level ofEvidence:C) B. PatientswithchronicsevereMR MR A. Asymptomaticpatientswithchronicsevere patients: 2. MVsurgeryisreasonableforthefollowing (Level ofEvidence:B) severe MR centers forasymptomaticpatientswithchronic biventricular pacing. optimal therapy forheartfailure, including NYHA functional classIII-IVsymptomsdespite dysfunction (EFlessthan0.30)who havepersistent † , preservedLV function,and(1)newonset (Level ofEvidence:C) † withpreservedLV function(EFgreater (Level ofEvidence: C) † duetosevereLV † duetoa Valve Surgery or Intervention 39 are almost or fungi) may (Level of Evidence: C) S. aureus (Level of Evidence: C) (Level of Evidence: Staphylococcus aureus Staphylococcus Objective definition of valve severity is provided in Table 1. in Table severity is provided Objective definition of valve 2. Isolated MV surgery is not indicated for patients MV surgery is not indicated 2. Isolated MR. with mild or moderate † patients with MR and preserved LV function (EF function LV MR and preserved patients with dimension less 0.60 and end-systolic greater than doubt about the in whom significant than 40 mm) repair exists. feasibility of for asymptomatic surgery is not indicated 1. MV make repair possible. caused by virulent organisms (such as always surgical diseases. Early surgery in MV endocarditis always surgical diseases. Early surgery in MV valve endocarditis caused by fungal endocarditis. Prosthetic valve endocarditis and native fungal endocarditis. Prosthetic valve endocarditis infections resistant to antibiotic therapy, and those with and those with infections resistant to antibiotic therapy, for patients with annular or aortic abscesses, those with for patients with annular or aortic abscesses, hemodynamics are less clear. Surgery is recommended hemodynamics are less clear. Indications for surgery for IE in patients with stable Indications for surgery for IE in patients with exists. of acute IE, surgery should not be delayed when of acute IE, surgery should not be delayed satisfactory quality of life after the operation. In the setting satisfactory quality of life after the operation. (IE) if the patient has a reasonable prospect of recovery with a reasonable prospect of recovery (IE) if the patient has heart disease with or without proven infective endocarditis without proven heart disease with or failure or cardiogenic due to surgically treatable valvular failure or cardiogenic Surgery is indicated in patients with life-threatening heart Surgery is indicated in E. Infective Endocarditis E. Class III Valve Surgery or Intervention IndicationsforSurgery forNative Valve Endocarditis Class I is preferabletoAVR forthesamereasons. be repairedaswellifthereareleafletperforations,andthis of infectionprostheticmaterials.Aorticvalvesmayoften of MVRinthesettingactiveinfectionbecauserisk When atallpossible, MVrepairshouldbeperformedinstead 40 1.Surgeryofthenativevalveisindicatedin (Level ofEvidence: B) endocarditis; or infection inannulusfibrosa). mitral leafletperforation withaorticvalve right atrium, , orleftatriumfistula; penetrating lesions(e.g.,sinusof Valsalva to annular oraorticabscess,destructive D. Patientswithcomplications ofheartblock, highly resistantorganisms. C. PatientswithIEcausedbyfungal orother hypertension). cutoff sign],ormoderateseverepulmonary signal bycontinuous-waveDoppler[ closure ofMVwithAR,rapiddeceleratingMR diastolic orleftatrialpressures(e.g.,premature hemodynamic evidenceofelevatedLV end- B. PatientswhopresentwithARorMR (Level ofEvidence:B) or regurgitationresultinginheartfailure. A. Patientswhopresentwithvalvestenosis following patientswithIE: (Level ofEvidence:B) (Level ofEvidence:B) v -wave Valve Surgery or Intervention 41 (Level of Evidence: C) (Level of Evidence: C) (Level of Evidence: (Level of Evidence: C) (Level of Evidence: B) C. Patients who present with evidence of increasing obstruction or worsening regurgitation. (Level of Evidence: C) with complications, for Patients who present D. abscess formation. example, for patients with IE of a prosthetic valve. for patients with IE of (Level of Evidence: C) 2. Surgery is indicated for the following patients with IE of a prosthetic valve: A. Patients who present with heart failure. (Level of Evidence: B) B. Patients who present with dehiscence evidenced by cine fluoroscopy or echocardiography. in patients with IE who present with mobile in patients with IE who of 10 mm with or without vegetations in excess emboli. patients with IE who present with recurrent emboli IE who present with patients with appropriate vegetations despite and persistent antibiotic therapy. of the native valve may be considered 1. Surgery is reasonable in of the native valve 1. Surgery surgeon is indicated 1. Consultation with a cardiac Class I for Prosthetic Valve Endocarditis Valve Prosthetic for Indications for Surgery Surgery for Indications Class IIb Class IIa Valve Surgery or Intervention regarding amechanical valveversusabioprosthesis isbased than forthoseless65years ofage.Thefinaldecision aortic positioninpatients65years ofageorgreaterislower deterioration. Therateofstructural valvedeteriorationinthe major disadvantageistheincreased rateofstructuralvalve prosthesis isthelackofneedfor antithrombotictherapy. The The majoradvantageofabioprosthesisover amechanical antithrombotic therapyandtheincreasedriskofthrombosis. tages areincreasedincidenceofbleedingduetoneedfor a bettersurvivalrateinyoungerpatients.Majordisadvan- prosthesis arealowrateofstructuraldeteriorationand The majoradvantagesofamechanicalvalveover abio- F. MajorCriteriafor Valve Selection Class III Class IIa 42 1.Routinesurgeryisnotindicatedforpatients 1.SurgeryisreasonableforpatientswithIE (Level ofEvidence:C) caused byfirstinfectionwithasensitiveorganism. with uncomplicatedIEofaprostheticvalve B. Relapsinginfection. (Level ofEvidence:C) emboli despiteappropriateantibiotictreatment. A. Evidenceofpersistentbacteremiaorrecurrent of aprostheticvalvewhopresentwith (Level ofEvidence:C) Valve Surgery or Intervention 43 (Level of Evidence: C) (Level of Evidence: C) 2. A bioprosthesis is recommended for AVR in patients of any age who will not take or who have major medical contraindications to warfarin therapy. for AVR in patients with a mechanical valve in patients with a mechanical valve for AVR in the mitral or tricuspid position. 1. A mechanical prosthesis is recommended valve is reduced. in another position), the major advantage of a biological in another position), the (i.e., atrial fibrillation or the presence of a mechanical valve (i.e., atrial fibrillation Class I Recommendations for Aortic Valve Selection Valve Aortic therapy for any reason If a patient needs antithrombotic for Recommendations rate of early structural valve deterioration. rate of early structural The disadvantage of a bioprosthesis is the relatively higher The disadvantage of a or UFH therapy that may affect the patient or the fetus. or UFH therapy that may of a mechanical valve are the complications of warfarin of a mechanical valve Pregnancy poses a difficult problem. The disadvantages Pregnancy poses a difficult are available to perform this procedure successfully. to perform this procedure are available feasible and that the appropriate skill level and experience skill level and experience that the appropriate feasible and In general, MV repair is preferable to MVR, provided it is to MVR, provided MV repair is preferable In general, and lifestyle. of the valve, relative contraindications to anticoagulation, to anticoagulation, relative contraindications of the valve, on multiple factors, including patient age, overall longevity longevity overall age, patient including factors, on multiple Valve Surgery or Intervention Class IIb Class IIa 44 1.Patientpreferenceisareasonableconsideration 1.Abioprosthesismight beconsideredforAVR in awomanofchildbearingage. endocarditis. reasonable forpatientswithactiveprostheticvalve 3. Aorticvalvere-replacementwithahomograftis thromboembolism. aged 65yearsorolderwithoutriskfactorsfor 2. AbioprosthesisisreasonableforAVR inpatients (Level ofEvidence:C) that asecondAVR maybenecessaryinthefuture. of therisksanticoagulationversuslikelihood for lifestyleconsiderationsafterdetaileddiscussions under 65yearsofagewhoelecttoreceivethisvalve A bioprosthesisisreasonableforAVR inpatients do nothaveacontraindicationtoanticoagulation. for AVR inpatientsunder65yearsofagewho prosthesis. Amechanicalprosthesisisreasonable in theselectionofaorticvalveoperationand (Level ofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:C) Valve Surgery or Intervention 45 (Level of Evidence: C) (Level of Evidence: C) (Level of Evidence: (Level of Evidence: C) 2. A bioprosthesis is reasonable for MVR in 2. A bioprosthesis is reasonable or older. patients 65 years of age (Level of Evidence: C) for MVR in 3. A bioprosthesis is reasonable of age in sinus rhythm patients under 65 years valve for lifestyle who elect to receive this the considerations after detailed discussions of risks of anticoagulation versus the likelihood that a second MVR may be necessary in the future. patient who will not take warfarin, is incapable will not take warfarin, patient who contraindication or has a clear of taking warfarin, therapy. to warfarin 65 years of age with MVR in patients under long-standing atrial fibrillation. for 1. A mechanical prosthesis is reasonable MVR in a is indicated for 1. A bioprosthesis Class IIa Class I Selection Valve Recommendations for Mitral Management of Prosthetic Valves to warfarintherapyshouldbeconsidered. patients whocannottakeaspirin, theadditionofclopidogrel valves andhigh-riskpatientswith bioprostheses.Inhigh-risk day) combinedwithwarfarininpatientsmechanicalheart bioprostheses andnoriskfactorsoraspirin(75to100mgper valves: aspirinalone(75to100mgperday)inpatientswith Aspirin isrecommendedforallpatientswithprostheticheart factors forthromboembolicevents. in thosepatientswithanew-generationAVR andnootherrisk (INR) is2.5to3.5.ThetargetINRcanbereduced2.03.0 mechanical prosthesis,thetargetinternationalnormalizedratio before thevalveisfullyendothelialized.Inmostpatientswitha of emboliishigherinthefirstfewmonthsaftervalveinsertion, events. With eithertypeofprosthesisorvalvelocation, therisk fibrillation, LV dysfunction,clottingdisorder, andpriorembolic risk factorsforincreasedofembolizationincludeatrial the valveinmitralpositionthanaorticposition.Other as indicatedin All patientswithmechanicalvalvesrequirewarfarintherapy, in Patients With Prosthetic Heart Valves A. Indicationsfor Anticoagulation of Prosthetic Heart Valves IV.Management Antithrombotic 46 Table 2 . Theriskofembolizationisgreaterwith

Management of Prosthetic Valves . 47 (see special situations in text) Aspirin Warfarin Warfarin = mitral valve replacement. MVR Recommendations for Antithrombotic Antithrombotic for Recommendations = aortic valve replacement; Less than 3 months Greater than 3 months Class I Class I Class IIa Class IIa Less than 3 months Greater than 3 months Class I Class I Class IIa Class IIb Class IIa Less than 3 months Greater than 3 months Class I Class I Class I Class I Class IIa ■ ■ ■ ■ ■ ■ Therapy in Patients With Prosthetic Heart Valves Heart Prosthetic With in Patients Therapy Table 2. Table Depending on patients’ clinical status, antithrombotic therapy must be individualized Depending on patients’ clinical status, antithrombotic therapy must be individualized AVR In patients receiving warfarin, aspirin is recommended in virtually all situations. Risk factors: atrial fibrillation, condition. INR should be maintained between dysfunction, previous thromboembolism, and hypercoagulable LV 2.5 and 3.5 for aortic SH. Modified from McAnulty JH, Rahimtoola valves. disk valves and Starr-Edwards editors. Hurst's The Heart.Antithrombotic therapy in valvular heart Alexander RW, disease. In: Schlant R, with permission McGraw-Hill, from the McGraw-Hill 1998:1867–74. Reprinted Companies. NY: New York, MVR – High Risk D. Class I Class I C. MVR – Low Risk C. – High Risk AVR B. Class I Class I A. AVR – Low Risk AVR A. Biological Prosthetic C. MVR MVR C. Class I Class I – High Risk AVR B. Class I Class I

A. AVR – Low Risk AVR A. Mechanical Prosthetic Type Valve (75-100 mg) (INR 2.0-3.0) (INR 2.5-3.5) Warfarin No Management of Prosthetic Valves inPatients With Prosthetic Heart Valves Class I Recommendations for Antithrombotic Therapy 48 1.AfterAVR withbileafletmechanicalorMedtronic INR of2.0to3.0. INR of2.5to3.5. risk factors, 6. AfterMVRwithabioprosthesis inpatientswith risk factors, 5. AfterAVR withabioprosthesisinpatients (Level ofEvidence:C) factors, 4. AfterAVR orMVRwithabioprosthesisandnorisk (Level ofEvidence:C) is indicatedtoachieveanINRof2.53.5. 3. AfterMVRwithanymechanicalvalve, warfarin (Level ofEvidence:B) an INRof2.5to3.5inpatientswithnoriskfactors. Hall prostheses),warfarinisindicatedtoachieve mechanical discvalves(otherthanMedtronic 2. AfterAVR withStarr-Edwardsvalvesor an INRof2.0to3.0inpatientswithnoriskfactors, Hall prostheses,warfarinisindicatedtoachieve risk factors. and toachieveanINRof2.53.5inpatientswith ‡ aspirinisindicatedat75to100mgperday. ‡ ‡ ‡ warfarinisindicatedtoachievean warfarinisindicatedtoachieve an (Level ofEvidence:B) (Level ofEvidence:C) (Level ofEvidence:C) ‡ ‡

Management of Prosthetic Valves 49 (Level of Evidence: B) it is reasonable to give warfarin to it is reasonable to give

‡ ‡ valves in whom aspirin cannot be used, it may valves in whom aspirin cannot be used, it day) be reasonable to give clopidogrel (75 mg per or warfarin to achieve an INR of 3.5 to 4.5. (Level of Evidence: C) (Level of Evidence: C) a mechanical prosthesis, it is reasonable to a mechanical prosthesis, an INR of 2.5 to 3.5. give warfarin to achieve (Level of Evidence: C) or MVR after AVR 2. During the first 3 months patients with no risk with a bioprosthesis in factors, 8. The addition of aspirin 75 to 100 mg once daily of aspirin 75 to 100 8. The addition for all warfarin is recommended to therapeutic heart valves and those patients with mechanical valves who have risk patients with biological factors. 7. For those patients who are unable to take unable who are those patients 7. For is indicated or MVR, aspirin AVR warfarin after 75 to 325 mg per day. in a dose of B) (Level of Evidence: thromboembolism, LV dysfunction, and hypercoagulable dysfunction, and hypercoagulable thromboembolism, LV condition. achieve an INR of 2.0 to 3.0. Risk factors include atrial fibrillation, previous ‡ 1. In high-risk patients with prosthetic heart with 1. During the first 3 months after AVR Class IIb Class IIa Management of Prosthetic Valves warfarin added. 325 mgperday, clopidogrel75mgperdayadded,and/or dose ofwarfarinisnotachievingthedesiredclinicalresult may alsoneedtobeincreased325mgperdayifthehigher be initiated increased toachieveINRof3.54.5 achieve INRof2.5to3.5 who arenotbleeding canbetreatedasfollows: the riskofthromboembolism.Patients withanINRof5to10 decreases inINRtolessthanthe therapeuticrangewillincrease warfarin andmonitoringthelevel ofanticoagulation.Rapid excessive anticoagulationcanbe managedbywithholding In mostpatientswithanINRabove thetherapeutic range, C. Excessive Anticoagulation ■ ■ ■ ■ ■ ally safe, asfollows: of antithrombotictherapyshouldbeincreased,whenclinic- undergoing adequateantithrombotictherapy, thedosage In thepatientwhohasadefiniteembolicepisodewhile B. EmbolicEventsDuring Adequate Antithrombotic Therapy 50 Aspirinalone:aspirindosemayneedtobeincreased Warfarin plusaspirin75to100mgperday:dose Nottakingaspirin:aspirin75to100mgperdayshould Warfarin, INR2.5to3.5:warfarindosemayneedbe Warfarin, INR2.0to3.0:warfarindoseincreased Management of Prosthetic Valves 51 it is recommended that warfarin be stopped it is recommended that warfarin be stopped § (Level of Evidence: B) those with a bileaflet mechanical AVR with no risk those with a bileaflet mechanical AVR factors, 48 to 72 h before the procedure (so the INR falls to 48 to 72 h before the procedure (so the INR the less than 1.5) and restarted within 24 h after procedure. Heparin is usually unnecessary. 1. In patients at low risk of thrombosis, defined as Emergency use of fresh frozen plasma is preferable to high- plasma is preferable to use of fresh frozen Emergency Restart warfarin and adjust dose appropriately to ensure the appropriately to ensure and adjust dose Restart warfarin Hold warfarin and administer 1 to 2.5 mg of oral vitamin K1 mg of oral 1 to 2.5 administer warfarin and Hold as needed INR after 24 h and subsequently Determine presence of a mitral prosthesis. Class I embolism, hypercoagulable condition, LV dysfunction, and the embolism, hypercoagulable condition, LV in Patients Therapy Antithrombotic risk factors, which include atrial fibrillation, previous thrombo- risk factors, which include atrial fibrillation, for Recommendations the warfarin is dependent on the absence or presence of other the warfarin is dependent molecular-weight heparin (LMWH) therapy when stopping molecular-weight heparin The use of “bridging” unfractionated heparin (UFH) or low- The use of “bridging” quences are severe, antithrombotic therapy should be altered. antithrombotic therapy should be altered. quences are severe, if it occurred. When bleeding is likely or its potential conse- if it occurred. When bleeding in which bleeding is either unlikely or would be inconsequential unlikely or would be inconsequential in which bleeding is either Requiring Noncardiac Surgery/Dental Care Surgery/Dental Requiring Noncardiac should not be stopped for procedures Antithrombotic therapy D. Antithrombotic Therapy Therapy Antithrombotic in Patients D. ■ ■ ■ ■ dose vitamin K1, especially parenteral vitamin K1. K1, especially parenteral dose vitamin INR is in the therapeutic range INR is in the Management of Prosthetic Valves Class IIb Class IIa 52 1.Itisreasonabletogivefreshfrozenplasma 1.Inpatientsathigh riskofthrombosis(seeabove), warfarin therapy. continued untiltheINRisagaintherapeuticwith early aftersurgeryasbleedingstabilityallows,and stopped 4to6hbeforetheprocedure, restartedas falls below2.0(typically48hbeforesurgery), intravenous UFHshouldbestartedwhentheINR AVR withanyriskfactor, as thosewithanymechanicalMVRora 2. Inpatientsathighriskofthrombosis,defined INR. be consideredduringtheperiodofasubtherapeutic every 12h)orLMWH(100Uperkgmay therapeutic dosesofsubcutaneousUFH(15,000U dose vitaminK1. care. Freshfrozenplasmaispreferabletohigh- noncardiac surgery, invasive procedures,ordental interruption ofwarfarintherapyforemergency to patientswithmechanicalvalveswhorequire (Level ofEvidence:B) (Level ofEvidence:B) (Level ofEvidence:B) § therapeuticdosesof Management of Prosthetic Valves 53 (Level of Evidence: B) (Level of Evidence: Risk factors: atrial fibrillation, previous thromboembolism, Risk factors: atrial fibrillation, LV dysfunction, hypercoagulable conditions, older generation generation conditions, older dysfunction, hypercoagulable LV tricuspid valves, or more thrombogenic valves, mechanical valve. than 1 mechanical

interruption of warfarin therapy for noncardiac of warfarin therapy interruption or dental care, procedures, invasive surgery, be given routinely, vitamin K1 should not high-dose may create a hypercoagulable because this condition.

§ valves who require with mechanical 1. In patients an increased risk of embryopathy. There are still insufficient an increased risk of embryopathy. of women with mechanical heart valves in pregnancy, but with pregnancy, of women with mechanical heart valves in is more efficacious than UFH for thromboembolic prophylaxis is more efficacious than UFH for thromboembolic complications, including fatal valve thrombosis. Thus, warfarin complications, including fatal valve thrombosis. for the fetus but poses a high incidence of thromboembolic for the fetus but poses a high incidence of studies strongly suggest that UFH or LMWH therapy is safe studies strongly suggest that UFH or LMWH a heparin compound several weeks before delivery. Several delivery. a heparin compound several weeks before of pregnancy, but needs to be discontinued and switched to but needs to be discontinued and switched of pregnancy, Warfarin is also relatively safe during the 2nd and 3rd trimester is also relatively safe during the 2nd and 3rd trimester Warfarin warfarin is taken between 6 and 12 weeks of gestation. warfarin is taken between 6 and 12 weeks 6 weeks of gestation, but there is a risk of embryopathy if 6 weeks of gestation, a difficult problem. Warfarin is probably safe during the first is probably a difficult problem. Warfarin Anticoagulation for prosthetic valves during pregnancy presents valves during pregnancy presents Anticoagulation for prosthetic E. Pregnancy E. Class III Management of Prosthetic Valves Patients With Mechanical Prosthetic ValvesMechanical Patients With Class I Selectionof Anticoagulation RegimeninPregnant monitoring isrequired. benefits ofeachapproach.Foranyanticoagulation,intensive requires discussionwiththepatientregardingrisksand performed. Thefinaldecisionontheanticoagulationregimen heart valvesbecauseproperlydesignedstudieshavenotbeen antithrombotic therapyinpregnantpatientswithmechanical grounds tomakedefinitiverecommendationsaboutoptimal 54 1.Allpregnantpatientswithmechanical valves upto36weeks ofgestation,thetherapeutic 4. Forpregnant patients withmechanicalprosthetic subcutaneous LMWH. IV UFH,dose-adjustedor 6 and12ofgestationshouldreceive continuous valves whoelecttostopwarfarin betweenweeks 3. Pregnantpatientswithmechanical prosthetic when pregnancyisachieved. anticoagulation canbecontinueduninterrupted subsequent anticoagulationtherapy, sothat should bemonitoredwithdiscussionsabout who areattemptingpregnancy, pregnancytests 2. Forwomenrequiringlong-termwarfarintherapy monitoring. therapeutic anticoagulationwithfrequent prosthetic valvesmustreceivecontinuous (Level ofEvidence:B) (Level ofEvidence:C) (Level ofEvidence:C) Management of Prosthetic Valves 55 (Level of Evidence: C) 8. In pregnant patients with mechanical pros- thetic valves, warfarin should be discontin- at ued and continuous IV UFH given starting 2 to 3 weeks before planned delivery. (Level of Evidence: C) (Level of Evidence: C) 7. In pregnant patients with mechanical pros- thetic valves who receive warfarin, the INR goal should be 3.0 (range 2.5 to 3.5). (Level of Evidence: C) (Level of Evidence: C) with mechanical pros- 6. In pregnant patients dose-adjusted UFH, thetic valves who receive least twice control. the aPTT should be at 5. In pregnant patients with mechanical pros- 5. In pregnant patients dose-adjusted LMWH, thetic valves who receive administered twice daily the LMWH should be the anti-Xa level subcutaneously to maintain 4 h after administration. between 0.7 to 1.2 units choice of continuous intravenous or adjusted-dose or adjusted-dose intravenous of continuous choice LMWH, or UFH, dose-adjusted subcutaneous If continuous be discussed fully. warfarin should but the the fetal risk is lower IV UFH is used, thrombosis, of prosthetic valve maternal risks osteoporosis and infection, systemic embolization, are relatively thrombocytopenia heparin-induced higher. Management of Prosthetic Valves both. Thecause maybedifficulttodetermineand requires thrombus formation, pannusingrowth,oracombination of Obstruction ofprosthetic heartvalvesmaybecaused by F. Thrombosis ofProsthetic Heart Valves Class III Class IIa 56 1.LMWHshouldnotbeadministeredtopregnant 1.Inpatientswithmechanicalprostheticvalves, (Level ofEvidence:B) valves becauseofitsharmfuleffects onthefetus. in pregnantpatientswithmechanicalprosthetic of aspirinasanalternativeantiplateletagent 2. Dipyridamoleshouldnotbeusedinstead administration. anti-Xa levelsaremonitored4to6hoursafter patients withmechanicalprostheticvalvesunless warfarin orheparin. of pregnancyinadditiontoanticoagulationwith 100 mgperday)inthesecondandthirdtrimesters it isreasonabletogivelow-doseaspirin(75 3. Inpatientswithmechanicalprostheticvalves, of significantbleeding. delivery andbeginoralwarfarinintheabsence it isreasonabletoresumeheparin46hafter 2. Inpatientswithmechanicalprostheticvalves, defects. 6 and12ofgestationowingtothehighriskfetal it isreasonabletoavoidwarfarinbetweenweeks (Level ofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:C) (Level ofEvidence:C) Management of Prosthetic Valves 57 (Level of Evidence: B) (Level of Evidence: C) B. Patients with a large clot burden. (Level of Evidence: C) 2. TEE and/or fluoroscopy is indicated in patients 2. TEE and/or fluoroscopy valve with suspected valve thrombosis to assess motion and clot burden. following patients with a thrombosed left sided prosthetic valve: A. Patients with NYHA functional class III-IV symptoms. is indicated in patients with suspected prosthetic is indicated in patients hemodynamic severity. valve thrombosis to assess (Level of Evidence: B) is reasonable for the 1. Emergency operation and Doppler echocardiography 1. Transthoracic Class IIa Class I those with stable hemodynamics and a small clot burden. those with stable hemodynamics Valves Heart of Prosthetic Recommendations for Thrombosis Thrombosis for or at high risk for surgery be used in patients 15%) but may Recommendations is associated with significant risks (cerebral emboli in 12% to (cerebral emboli in with significant risks is associated therapy for a left-sided prosthetic valve obstructed by thrombus valve obstructed by a left-sided prosthetic therapy for failure or the patient with a large thrombus burden. Fibrinolytic thrombus burden. Fibrinolytic patient with a large failure or the indicated for the patient with NYHA functional class III-IV heart functional class III-IV the patient with NYHA indicated for echocardiography, including TEE. Emergency surgery is TEE. Emergency including echocardiography, knowledge of the clinical presentation and findings on and findings clinical presentation of the knowledge Management of Prosthetic Valves Class IIb 58 1.Fibrinolytictherapymaybeconsideredas burden. functional classIII-IVsymptomsoralargeclot right-sided prostheticheartvalveswithNYHA 2. Fibrinolytictherapyisreasonableforthrombosed (Level ofEvidence:C) functional classI-IIandhaveasmall clotburden. with athrombosedvalvewhoareinNYHA fibrinolytic therapymaybeconsideredforpatients 2. Intravenousheparinasanalternativeto is highriskornotavailable. and alargeclotburdenifemergencysurgery who haveNYHAfunctionalclassII-IVsymptoms C. Patientswithanobstructedprostheticvalve is highriskornotavailable. symptoms, andasmallclotburdenifsurgery B. PatientswithaNYHAfunctionalclassIII-IV (Level ofEvidence:B) symptoms, andasmallclotburden. A. PatientswithNYHAfunctionalclassI-II with athrombosedleftsidedprostheticvalve: a first-linetherapyforthefollowingpatients (Level ofEvidenceC) (Level ofEvidence:C) (Level ofEvidence:B) History/Exam Eval/Treat Lower Extremity Renal Mesenteric Aneurysms 2 UC200700026 EN