Journal of the American College of Cardiology Vol. 63, No. 22, 2014 Ó 2014 by the American Heart Association, Inc., and the American College of Cardiology Foundation ISSN 0735-1097/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2014.02.536 PRACTICE GUIDELINE 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons Writing Rick A. Nishimura, MD, MACC, FAHA, Paul Sorajja, MD, FACC, FAHA# Committee Co-Chairy Thoralf M. Sundt III, MD***yy Members* Catherine M. Otto, MD, FACC, FAHA, James D. Thomas, MD, FASE, FACC, FAHAzz Co-Chairy *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and Robert O. Bonow, MD, MACC, FAHAy other entities may apply; see Appendix 1 for recusal information. yACC/ y AHA representative. zACC/AHA Task Force on Performance Measures Blase A. Carabello, MD, FACC* x { z liaison. ACC/AHA Task Force on Practice Guidelines liaison. Society John P. Erwin III, MD, FACC, FAHA of Cardiovascular Anesthesiologists representative. #Society for Cardio- Robert A. Guyton, MD, FACC*x vascular Angiography and Interventions representative. **American ’ y Association for Thoracic Surgery representative. yySociety of Thoracic Patrick T. O Gara, MD, FACC, FAHA Surgeons representative. zzAmerican Society of Echocardiography Carlos E. Ruiz, MD, PHD, FACCy representative. Nikolaos J. Skubas, MD, FASE{ ACC/AHA Task Jeffrey L. Anderson, MD, FACC, FAHA, Robert A. Guyton, MD, FACCxx Force Members Chair Judith S. Hochman, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA, Richard J. Kovacs, MD, FACC, FAHA Chair-Elect E. Magnus Ohman, MD, FACC Susan J. Pressler, PHD, RN, FAHA Nancy M. Albert, PHD, CCNS, CCRN, FAHA Frank W. Sellke, MD, FACC, FAHA Biykem Bozkurt, MD, PHD, FACC, FAHA Win-Kuang Shen, MD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC William G. Stevenson, MD, FACC, FAHAxx Mark A. Creager, MD, FACC, FAHAxx Clyde W. Yancy, MD, FACC, FAHAxx Lesley H. Curtis, PHD, FAHA xxFormer Task Force member during the writing effort. David DeMets, PHD This document was approved by the American College of Cardiology Board of Copies: This document is available on the World Wide Web sites of the Trustees and the American Heart Association Science Advisory and Coordinating American College of Cardiology (www.cardiosource.org) and the American Heart Committee in January 2014. Association (my.americanheart.org). For copies of this document, please contact the The American College of Cardiology requests that this document be cited as follows: Elsevier Inc. Reprint Department via fax (212) 633–3820 or e-mail reprints@ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, elsevier.com. O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD. 2014 AHA/ Permissions: Multiple copies, modification, alteration, enhancement, and/or ACC guideline for the management of patients with valvular heart disease: a report distribution of this document are not permitted without the express permission of of the American College of Cardiology/American Heart Association Task Force the American College of Cardiology. Requests may be completed online via on Practice Guidelines. J Am Coll Cardiol 2014;63:e57–185. the Elsevier site (http://www.elsevier.com/authors/obtaining-permission-to-re-use- This article has been copublished in Circulation. elsevier-material). e58 Nishimura et al. JACC Vol. 63, No. 22, 2014 2014 AHA/ACC Valvular Heart Disease Guideline June 10, 2014:e57–185 4.3.1. Diagnosis and Follow-Up ...............e83 TABLE OF CONTENTS 4.3.1.1. DIAGNOSTIC TESTINGdINITIAL DIAGNOSIS: RECOMMENDATIONS ................. e83 Preamble ...........................................e60 4.3.1.2. DIAGNOSTIC TESTINGdCHANGING SIGNS OR SYMPTOMS ....................... e85 4.3.1.3. DIAGNOSTIC TESTINGdROUTINE FOLLOW-UP . e85 1. Introduction ...................................e62 4.3.1.4. DIAGNOSTIC TESTINGdCARDIAC CATHETERIZATION .................. e85 d 1.1. Methodology and Evidence Review .........e62 4.3.1.5. DIAGNOSTIC TESTING EXERCISE TESTING . e85 4.3.2. Medical Therapy: Recommendations ......e85 1.2. Organization of the Writing Committee .....e62 4.3.3. Timing of Intervention: 1.3. Document Review and Approval ............e62 Recommendations ......................e86 1.4. Scope of the Guideline .....................e62 5. Bicuspid Aortic Valve and Aortopathy .........e88 2. General Principles .............................e63 5.1. Bicuspid Aortic Valve 2.1. Evaluation of the Patient With .......................e88 Suspected VHD ............................e63 5.1.1. Diagnosis and Follow-Up ...............e88 5.1.1.1. DIAGNOSTIC TESTINGdINITIAL DIAGNOSIS: fi 2.2. De nitions of Severity of Valve Disease ....e64 RECOMMENDATIONS ................. e88 2.3. Diagnosis and Follow-Up ....................e64 5.1.1.2. DIAGNOSTIC TESTINGdROUTINE FOLLOW-UP: RECOMMENDATION ................. e89 2.3.1. Diagnostic Testing–Initial Diagnosis: 5.1.2. Medical Therapy .......................e89 Recommendation ......................e64 5.1.3. Intervention: Recommendations ..........e89 2.3.2. Diagnostic TestingdChanging Signs or Symptoms: Recommendation ............e65 6. Mitral Stenosis ................................e90 2.3.3. Diagnostic TestingdRoutine Follow-Up: Recommendation ......................e65 6.1. Stages of MS ..............................e90 2.3.4. Diagnostic TestingdCardiac 6.2. Rheumatic MS .............................e90 Catheterization: Recommendation ........e65 2.3.5. Diagnostic TestingdExercise Testing: 6.2.1. Diagnosis and Follow-Up ...............e90 6.2.1.1. DIAGNOSTIC TESTINGdINITIAL DIAGNOSIS: Recommendation ......................e65 RECOMMENDATIONS ................. e90 2.4. Basic Principles of Medical Therapy ........e66 6.2.1.2. DIAGNOSTIC TESTINGdCHANGING SIGNS OR 2.4.1. Secondary Prevention of Rheumatic Fever: SYMPTOMS ....................... e91 Recommendation ......................e66 6.2.1.3. DIAGNOSTIC TESTINGdROUTINE FOLLOW-UP . e91 d 2.4.2. IE Prophylaxis: Recommendations ........e67 6.2.1.4. DIAGNOSTIC TESTING CARDIAC CATHETERIZATION .................. e92 2.5. Evaluation of Surgical and 6.2.1.5. DIAGNOSTIC TESTINGdEXERCISE TESTING: Interventional Risk .........................e68 RECOMMENDATION ................. e93 2.6. The Heart Valve Team and Heart Valve Centers 6.2.2. Medical Therapy: Recommendations ......e93 of Excellence: Recommendations ...........e69 6.2.3. Intervention: Recommendations ..........e94 6.3. Nonrheumatic MS ..........................e96 3. Aortic Stenosis ................................e71 7. Mitral Regurgitation ...........................e97 3.1. Stages of Valvular AS ......................e71 3.2. Aortic Stenosis ............................e71 7.1. Acute MR ..................................e97 3.2.1. Diagnosis and Follow-Up ...............e71 7.1.1. Diagnosis and Follow-Up ...............e97 3.2.1.1. DIAGNOSTIC TESTINGdINITIAL DIAGNOSIS: 7.1.2. Medical Therapy .......................e97 RECOMMENDATIONS ................. e71 7.1.3. Intervention ...........................e98 3.2.1.2. DIAGNOSTIC TESTINGdCHANGING SIGNS OR 7.2. Stages of Chronic MR ......................e98 SYMPTOMS ....................... e73 7.3. Chronic Primary MR 3.2.1.3. DIAGNOSTIC TESTINGdROUTINE FOLLOW-UP . e73 ........................e98 3.2.1.4. DIAGNOSTIC TESTINGdCARDIAC 7.3.1. Diagnosis and Follow-Up ...............e98 CATHETERIZATION .................. e73 7.3.1.1. DIAGNOSTIC TESTINGdINITIAL DIAGNOSIS: 3.2.1.5. DIAGNOSTIC TESTINGdEXERCISE TESTING: RECOMMENDATIONS ................. e98 RECOMMENDATIONS ................. e74 7.3.1.2. DIAGNOSTIC TESTINGdCHANGING SIGNS OR 3.2.2. Medical Therapy: Recommendations ......e74 SYMPTOMS . e101 3.2.3. Timing of Intervention: 7.3.1.3. DIAGNOSTIC TESTINGdROUTINE FOLLOW-UP ..e101 d Recommendations ......................e75 7.3.1.4. DIAGNOSTIC TESTING CARDIAC CATHETERIZATION . e101 3.2.4. Choice of Intervention: Recommendation ...e79 7.3.1.5. DIAGNOSTIC TESTINGdEXERCISE TESTING: RECOMMENDATIONS . e102 4. Aortic Regurgitation ...........................e82 7.3.2. Medical Therapy: Recommendations . e102 7.3.3. Intervention: Recommendations . e102 4.1. Acute AR ..................................e82 7.4. Chronic Secondary MR . e106 4.1.1. Diagnosis .............................e83 7.4.1. Diagnosis and Follow-Up: 4.1.2. Intervention ...........................e83 Recommendations . e106 4.2. Stages of Chronic AR ......................e83 7.4.2. Medical Therapy: Recommendations . e106 4.3. Chronic AR .................................e83 7.4.3. Intervention: Recommendations . e107 JACC Vol. 63, No. 22, 2014 Nishimura et al. e59 June 10, 2014:e57–185 2014 AHA/ACC Valvular Heart Disease Guideline 8. Tricuspid Valve Disease . e107 12. Infective Endocarditis . e129 8.1. Stages of TR . e107 12.1. IE: Overview . e129 8.2. Tricuspid Regurgitation . e108 12.2. Infective Endocarditis . e129 8.2.1. Diagnosis and Follow-Up: 12.2.1. Diagnosis and Follow-Up: Recommendations . e108 Recommendations . e130 8.2.2. Medical Therapy: Recommendations . e111 12.2.2. Medical Therapy: Recommendations ..e134 8.2.3. Intervention: Recommendations