February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e72 WRITING COMMITTEE MEMBERS* Catherine M. Otto, MD, FACC, FAHA, Co-Chair Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Robert O. Bonow, MD, MS, MACC, FAHA Blase A. Carabello, MD, FACC, FAHA John P. Erwin III, MD, FACC, FAHA Federico Gentile, MD, FACC Hani Jneid, MD, FACC, FAHA Eric V. Krieger, MD, FACC Michael Mack, MD, MACC Christopher McLeod, MBCHB, PhD, FAHA Patrick T. O’Gara, MD, MACC, FAHA† Vera H. Rigolin, MD, FACC, FAHA Thoralf M. Sundt III, MD, FACC, FAHA Annemarie Thompson, MD Christopher Toly © 2020 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA CLINICAL PRACTICE GUIDELINE 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Circulation https://www.ahajournals.org/journal/circ Developed in collaboration with and endorsed by 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 ACC/AHA Joint Committee on Clinical Practice Guidelines Members, see page e184 *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. The American Heart Association requests that this document be cited as follows: Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72-e227. doi: 10.1161/CIR.0000000000000923 Key Words: AHA Scientific Statements ◼ anticoagulation therapy ◼ aortic regurgitation ◼ aortic stenosis ◼ bicuspid aortic valve ◼ cardiac surgery ◼ guidelines ◼ infective endocarditis ◼ mitral regurgitation ◼ mitral stenosis ◼ mitral transcatheter edge-to-edge repair ◼ prosthetic valve ◼ pulmonic regurgitation ◼ pulmonic stenosis ◼ transcatheter aortic valve replacement or implantation ◼ tricuspid regurgitation ◼ tricuspid stenosis ◼ valvular heart disease Downloaded from http://ahajournals.org by on July 24, 2021
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease
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2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice GuidelinesFebruary 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923e72
WRITING COMMITTEE MEMBERS* Catherine M. Otto, MD, FACC, FAHA, Co-Chair Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Robert O. Bonow, MD, MS, MACC, FAHA Blase A. Carabello, MD, FACC, FAHA John P. Erwin III, MD, FACC, FAHA Federico Gentile, MD, FACC Hani Jneid, MD, FACC, FAHA Eric V. Krieger, MD, FACC Michael Mack, MD, MACC Christopher McLeod, MBCHB, PhD, FAHA Patrick T. O’Gara, MD, MACC, FAHA† Vera H. Rigolin, MD, FACC, FAHA Thoralf M. Sundt III, MD, FACC, FAHA Annemarie Thompson, MD Christopher Toly
© 2020 by the American College of Cardiology Foundation and the American Heart Association, Inc.
ACC/AHA CLINICAL PRACTICE GUIDELINE
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Circulation
https://www.ahajournals.org/journal/circ
Developed in collaboration with and endorsed by 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
ACC/AHA Joint Committee on Clinical Practice Guidelines Members, see page e184
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison.
The American Heart Association requests that this document be cited as follows: Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72-e227. doi: 10.1161/CIR.0000000000000923
Key Words: AHA Scientific Statements anticoagulation therapy aortic regurgitation aortic stenosis bicuspid aortic valve cardiac surgery guidelines infective endocarditis mitral regurgitation mitral stenosis mitral transcatheter edge-to-edge repair prosthetic valve pulmonic regurgitation pulmonic stenosis transcatheter aortic valve replacement or implantation tricuspid regurgitation tricuspid stenosis valvular heart disease
D ow
Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e73
CLINICAL STATEM ENTS
AND GUIDELINES
TABLE OF CONTENTS Top 10 Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . e74 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e75 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e76
1.1. Methodology and Evidence Review . . . . . . . . . . . e76 1.2. Organization of the Writing Committee . . . . . . . . e76 1.3. Document Review and Approval . . . . . . . . . . . . . . e76 1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . e76 1.5. Class of Recommendation and Level of Evidence . e77 1.6. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e77
2. General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e78 2.1. Evaluation of the Patient With Known or
Suspected Native VHD . . . . . . . . . . . . . . . . . . . . . . e78 2.2. Definitions of Severity of Valve Disease . . . . . . . . e78 2.3. Diagnosis and Follow-Up . . . . . . . . . . . . . . . . . . . . e78
2.3.1. Diagnostic Testing: Initial Diagnosis 30 . . . e78 2.3.2. Diagnostic Testing: Changing Signs or
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . e80 2.3.3. Diagnostic Testing: Routine Follow-Up . . . e80 2.3.4. Diagnostic Testing: Cardiac Catheterization . .e81 2.3.5. Diagnostic Testing: Exercise Testing . . . . . . e81
2.4. Basic Principles of Medical Therapy . . . . . . . . . . . . e81 2.4.1. Secondary Prevention of Rheumatic Fever e82 2.4.2. IE Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . e82 2.4.3. Anticoagulation for AF in Patients With VHD e83
2.5. Evaluation of Surgical and Interventional Risk . . . e85 2.6. The Multidisciplinary Heart Valve Team and
Heart Valve Centers . . . . . . . . . . . . . . . . . . . . . . . . e86 2.7. Management of Patients With VHD After Valve
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e88 2.7.1. Procedural Complications . . . . . . . . . . . . . . e89 2.7.2. Primary and Secondary Risk Factor
Evaluation and Treatment . . . . . . . . . . . . . . e89 2.7.3. Persistent Symptoms After Valve Intervention . .e89 2.7.4. Periodic Imaging After Valve Intervention . e89
3. Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e90 3.1. Stages of Valvular AS . . . . . . . . . . . . . . . . . . . . . . . e90 3.2. Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e90
3.2.1. Diagnosis and Follow-Up . . . . . . . . . . . . . . e90 3.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . . e93 3.2.3. Timing of Intervention . . . . . . . . . . . . . . . . e94 3.2.4. Choice of Intervention . . . . . . . . . . . . . . . . e97
4. Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . e104 4.1. Acute Aortic Regurgitation . . . . . . . . . . . . . . . . . e104
4.1.1. Diagnosis of AR . . . . . . . . . . . . . . . . . . . . . e104 4.1.2. Intervention . . . . . . . . . . . . . . . . . . . . . . . . e104
4.2. Stages of Chronic AR . . . . . . . . . . . . . . . . . . . . . . e104 4.3. Chronic AR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e106
4.3.1. Diagnosis of Chronic AR . . . . . . . . . . . . . . e106 4.3.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . e106 4.3.3. Timing of Intervention . . . . . . . . . . . . . . . e107
5. Bicuspid Aortic Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . e109 5.1. BAV and Associated Aortopathy . . . . . . . . . . . . . e109
5.1.1. Diagnosis and Follow-Up of BAV . . . . . . . e109 5.1.2. Interventions for Patients With BAV . . . . e109
6. Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e112 6.1. Stages of MS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e113 6.2. Rheumatic MS . . . . . . . . . . . . . . . . . . . . . . . . . . . . e113
6.2.1. Diagnosis and Follow-Up of Rheumatic MS e113 6.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . e115
6.2.3. Intervention . . . . . . . . . . . . . . . . . . . . . . . e116 6.3. Nonrheumatic Calcific MS . . . . . . . . . . . . . . . . . e118
7. Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . e119 7.1. Acute MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e119
7.1.1. Diagnosis of Acute MR . . . . . . . . . . . . . . e119 7.1.2. Medical Therapy . . . . . . . . . . . . . . . . . . . e119 7.1.3. Intervention . . . . . . . . . . . . . . . . . . . . . . . e119
7.2. Chronic Primary MR . . . . . . . . . . . . . . . . . . . . . . e119 7.2.1. Stages of Chronic Primary MR . . . . . . . . e119 7.2.2. Diagnosis and Follow-Up of Chronic
Primary MR . . . . . . . . . . . . . . . . . . . . . . . e120 7.2.3. Medical Therapy . . . . . . . . . . . . . . . . . . . e123 7.2.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . e124
7.3. Chronic Secondary MR . . . . . . . . . . . . . . . . . . . e126 7.3.1. Stages of Chronic Secondary MR . . . . . e126 7.3.2. Diagnosis of Chronic Secondary MR . . . e127 7.3.3. Medical Therapy . . . . . . . . . . . . . . . . . . . e128 7.3.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . e129
8. Tricuspid Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . e131 8.1. Classification and Stages of TR . . . . . . . . . . . . . e131 8.2. Tricuspid Regurgitation . . . . . . . . . . . . . . . . . . . e131
8.2.1. Diagnosis of TR . . . . . . . . . . . . . . . . . . . . e131 8.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . e132 8.2.3. Timing of Intervention . . . . . . . . . . . . . . e133
9. Pulmonic Valve Disease . . . . . . . . . . . . . . . . . . . . . e135 10. Mixed Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . . . e135
10.1. Diagnosis of Mixed VHD . . . . . . . . . . . . . . . . . . e135 10.2. Timing of Intervention for Mixed VHD . . . . . . e136
10.2.1. Intervention for Mixed AS and AR . . . e136 10.2.2. Intervention for Mixed AS and MR . . . e136 10.2.3. Intervention for Mixed MS and MR . . e137 10.2.4. Intervention for Mixed MS and AR . . . e137 10.2.5. Intervention for Mixed MS and AS . . . e137
11. Prosthetic Valves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e137 11.1. Evaluation and Selection of Prosthetic Valves . e137
11.1.1. Diagnosis and Follow-Up of Prosthetic Valves . . . . . . . . . . . . . . . . . . . . . . . . . . e137
11.1.2. Selection of Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve e139
11.2. Antithrombotic Therapy . . . . . . . . . . . . . . . . . . e142 11.3. Bridging Therapy . . . . . . . . . . . . . . . . . . . . . . . . e146 11.4. Excessive Anticoagulation and Serious
Bleeding With Prosthetic Valves . . . . . . . . . . . e148 11.5. Thromboembolic Events With Prosthetic Valves . e148 11.6. Acute Mechanical Valve Thrombosis . . . . . . . . e149
11.6.1. Diagnosis of Acute Mechanical Valve Thrombosis . . . . . . . . . . . . . . . . . . . . . . e149
11.6.2. Intervention . . . . . . . . . . . . . . . . . . . . . e150 11.7. Bioprosthetic Valve Thrombosis . . . . . . . . . . . . e150
11.7.1. Diagnosis of Bioprosthetic Valve Thrombosis . . . . . . . . . . . . . . . . . . . . . . e150
11.7.2. Medical Therapy . . . . . . . . . . . . . . . . . . e150 11.8. Prosthetic Valve Stenosis . . . . . . . . . . . . . . . . . . e151
11.8.1. Diagnosis of Prosthetic Valve Stenosis . . . e151 11.8.2. Intervention for Prosthetic Valve Stenosis . e152
11.9. Prosthetic Valve Regurgitation . . . . . . . . . . . . . e152 11.9.1. Diagnosis of Prosthetic Valve
Regurgitation . . . . . . . . . . . . . . . . . e153 11.9.2. Medical Therapy . . . . . . . . . . . . . . . . . . e154 11.9.3. Intervention . . . . . . . . . . . . . . . . . . . . . e154
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nloaded from http://ahajournals.org by on July 24, 2021
Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease
February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923e74
CL IN
IC AL
S TA
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EN TS
12. Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . e155 12.1. Classification of Endocarditis . . . . . . . . . . . . . . e155 12.2. Diagnosis of IE . . . . . . . . . . . . . . . . . . . . . . . . . e156 12.3. Medical Therapy . . . . . . . . . . . . . . . . . . . . . . . . e160 12.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . e162
13. Pregnancy and VHD . . . . . . . . . . . . . . . . . . . . . . . . . . e165 13.1. Initial Management of Women With VHD
Before and During Pregnancy . . . . . . . . . . . . . e165 13.1.1. Medical Therapy for Women With
VHD Before and During Pregnancy . e166 13.1.2. Intervention for Women With Native
VHD Before and During Pregnancy . e166 13.2. Prosthetic Valves in Pregnant Women . . . . . . e169
13.2.1. Initial Management . . . . . . . . . . . . . . e169 13.2.2. Anticoagulation for Pregnant Women
With Mechanical Prosthetic Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . . e170
14. Surgical Considerations . . . . . . . . . . . . . . . . . . . . . . . e174 14.1. Evaluation and Management of CAD in
Patients With VHD . . . . . . . . . . . . . . . . . . . . . . e174 14.1.1. Management of CAD in Patients
Undergoing TAVI . . . . . . . . . . . . . . . . e174 14.1.2. Management of CAD in Patients
Undergoing Valve Surgery . . . . . . . . . e176 14.2. Intervention for AF in Patients With VHD . . . e177
15. Noncardiac Surgery in Patients With VHD . . . . . . . . e178 15.1. Diagnosis of Patients With VHD Undergoing
Noncardiac Surgery . . . . . . . . . . . . . . . . . . . . . e178 15.2. Management of the Symptomatic Patient . . . e179 15.3. Management of the Asymptomatic Patient . . e180
16. Evidence Gaps and Future Directions . . . . . . . . . . .…
WRITING COMMITTEE MEMBERS* Catherine M. Otto, MD, FACC, FAHA, Co-Chair Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Robert O. Bonow, MD, MS, MACC, FAHA Blase A. Carabello, MD, FACC, FAHA John P. Erwin III, MD, FACC, FAHA Federico Gentile, MD, FACC Hani Jneid, MD, FACC, FAHA Eric V. Krieger, MD, FACC Michael Mack, MD, MACC Christopher McLeod, MBCHB, PhD, FAHA Patrick T. O’Gara, MD, MACC, FAHA† Vera H. Rigolin, MD, FACC, FAHA Thoralf M. Sundt III, MD, FACC, FAHA Annemarie Thompson, MD Christopher Toly
© 2020 by the American College of Cardiology Foundation and the American Heart Association, Inc.
ACC/AHA CLINICAL PRACTICE GUIDELINE
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Circulation
https://www.ahajournals.org/journal/circ
Developed in collaboration with and endorsed by 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
ACC/AHA Joint Committee on Clinical Practice Guidelines Members, see page e184
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison.
The American Heart Association requests that this document be cited as follows: Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72-e227. doi: 10.1161/CIR.0000000000000923
Key Words: AHA Scientific Statements anticoagulation therapy aortic regurgitation aortic stenosis bicuspid aortic valve cardiac surgery guidelines infective endocarditis mitral regurgitation mitral stenosis mitral transcatheter edge-to-edge repair prosthetic valve pulmonic regurgitation pulmonic stenosis transcatheter aortic valve replacement or implantation tricuspid regurgitation tricuspid stenosis valvular heart disease
D ow
Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e73
CLINICAL STATEM ENTS
AND GUIDELINES
TABLE OF CONTENTS Top 10 Take-Home Messages . . . . . . . . . . . . . . . . . . . . . . . e74 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e75 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e76
1.1. Methodology and Evidence Review . . . . . . . . . . . e76 1.2. Organization of the Writing Committee . . . . . . . . e76 1.3. Document Review and Approval . . . . . . . . . . . . . . e76 1.4. Scope of the Guideline . . . . . . . . . . . . . . . . . . . . . . e76 1.5. Class of Recommendation and Level of Evidence . e77 1.6. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e77
2. General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e78 2.1. Evaluation of the Patient With Known or
Suspected Native VHD . . . . . . . . . . . . . . . . . . . . . . e78 2.2. Definitions of Severity of Valve Disease . . . . . . . . e78 2.3. Diagnosis and Follow-Up . . . . . . . . . . . . . . . . . . . . e78
2.3.1. Diagnostic Testing: Initial Diagnosis 30 . . . e78 2.3.2. Diagnostic Testing: Changing Signs or
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . e80 2.3.3. Diagnostic Testing: Routine Follow-Up . . . e80 2.3.4. Diagnostic Testing: Cardiac Catheterization . .e81 2.3.5. Diagnostic Testing: Exercise Testing . . . . . . e81
2.4. Basic Principles of Medical Therapy . . . . . . . . . . . . e81 2.4.1. Secondary Prevention of Rheumatic Fever e82 2.4.2. IE Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . e82 2.4.3. Anticoagulation for AF in Patients With VHD e83
2.5. Evaluation of Surgical and Interventional Risk . . . e85 2.6. The Multidisciplinary Heart Valve Team and
Heart Valve Centers . . . . . . . . . . . . . . . . . . . . . . . . e86 2.7. Management of Patients With VHD After Valve
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e88 2.7.1. Procedural Complications . . . . . . . . . . . . . . e89 2.7.2. Primary and Secondary Risk Factor
Evaluation and Treatment . . . . . . . . . . . . . . e89 2.7.3. Persistent Symptoms After Valve Intervention . .e89 2.7.4. Periodic Imaging After Valve Intervention . e89
3. Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e90 3.1. Stages of Valvular AS . . . . . . . . . . . . . . . . . . . . . . . e90 3.2. Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e90
3.2.1. Diagnosis and Follow-Up . . . . . . . . . . . . . . e90 3.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . . e93 3.2.3. Timing of Intervention . . . . . . . . . . . . . . . . e94 3.2.4. Choice of Intervention . . . . . . . . . . . . . . . . e97
4. Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . e104 4.1. Acute Aortic Regurgitation . . . . . . . . . . . . . . . . . e104
4.1.1. Diagnosis of AR . . . . . . . . . . . . . . . . . . . . . e104 4.1.2. Intervention . . . . . . . . . . . . . . . . . . . . . . . . e104
4.2. Stages of Chronic AR . . . . . . . . . . . . . . . . . . . . . . e104 4.3. Chronic AR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e106
4.3.1. Diagnosis of Chronic AR . . . . . . . . . . . . . . e106 4.3.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . e106 4.3.3. Timing of Intervention . . . . . . . . . . . . . . . e107
5. Bicuspid Aortic Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . e109 5.1. BAV and Associated Aortopathy . . . . . . . . . . . . . e109
5.1.1. Diagnosis and Follow-Up of BAV . . . . . . . e109 5.1.2. Interventions for Patients With BAV . . . . e109
6. Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e112 6.1. Stages of MS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e113 6.2. Rheumatic MS . . . . . . . . . . . . . . . . . . . . . . . . . . . . e113
6.2.1. Diagnosis and Follow-Up of Rheumatic MS e113 6.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . . e115
6.2.3. Intervention . . . . . . . . . . . . . . . . . . . . . . . e116 6.3. Nonrheumatic Calcific MS . . . . . . . . . . . . . . . . . e118
7. Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . e119 7.1. Acute MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e119
7.1.1. Diagnosis of Acute MR . . . . . . . . . . . . . . e119 7.1.2. Medical Therapy . . . . . . . . . . . . . . . . . . . e119 7.1.3. Intervention . . . . . . . . . . . . . . . . . . . . . . . e119
7.2. Chronic Primary MR . . . . . . . . . . . . . . . . . . . . . . e119 7.2.1. Stages of Chronic Primary MR . . . . . . . . e119 7.2.2. Diagnosis and Follow-Up of Chronic
Primary MR . . . . . . . . . . . . . . . . . . . . . . . e120 7.2.3. Medical Therapy . . . . . . . . . . . . . . . . . . . e123 7.2.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . e124
7.3. Chronic Secondary MR . . . . . . . . . . . . . . . . . . . e126 7.3.1. Stages of Chronic Secondary MR . . . . . e126 7.3.2. Diagnosis of Chronic Secondary MR . . . e127 7.3.3. Medical Therapy . . . . . . . . . . . . . . . . . . . e128 7.3.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . e129
8. Tricuspid Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . e131 8.1. Classification and Stages of TR . . . . . . . . . . . . . e131 8.2. Tricuspid Regurgitation . . . . . . . . . . . . . . . . . . . e131
8.2.1. Diagnosis of TR . . . . . . . . . . . . . . . . . . . . e131 8.2.2. Medical Therapy . . . . . . . . . . . . . . . . . . . e132 8.2.3. Timing of Intervention . . . . . . . . . . . . . . e133
9. Pulmonic Valve Disease . . . . . . . . . . . . . . . . . . . . . e135 10. Mixed Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . . . e135
10.1. Diagnosis of Mixed VHD . . . . . . . . . . . . . . . . . . e135 10.2. Timing of Intervention for Mixed VHD . . . . . . e136
10.2.1. Intervention for Mixed AS and AR . . . e136 10.2.2. Intervention for Mixed AS and MR . . . e136 10.2.3. Intervention for Mixed MS and MR . . e137 10.2.4. Intervention for Mixed MS and AR . . . e137 10.2.5. Intervention for Mixed MS and AS . . . e137
11. Prosthetic Valves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e137 11.1. Evaluation and Selection of Prosthetic Valves . e137
11.1.1. Diagnosis and Follow-Up of Prosthetic Valves . . . . . . . . . . . . . . . . . . . . . . . . . . e137
11.1.2. Selection of Prosthetic Valve Type: Bioprosthetic Versus Mechanical Valve e139
11.2. Antithrombotic Therapy . . . . . . . . . . . . . . . . . . e142 11.3. Bridging Therapy . . . . . . . . . . . . . . . . . . . . . . . . e146 11.4. Excessive Anticoagulation and Serious
Bleeding With Prosthetic Valves . . . . . . . . . . . e148 11.5. Thromboembolic Events With Prosthetic Valves . e148 11.6. Acute Mechanical Valve Thrombosis . . . . . . . . e149
11.6.1. Diagnosis of Acute Mechanical Valve Thrombosis . . . . . . . . . . . . . . . . . . . . . . e149
11.6.2. Intervention . . . . . . . . . . . . . . . . . . . . . e150 11.7. Bioprosthetic Valve Thrombosis . . . . . . . . . . . . e150
11.7.1. Diagnosis of Bioprosthetic Valve Thrombosis . . . . . . . . . . . . . . . . . . . . . . e150
11.7.2. Medical Therapy . . . . . . . . . . . . . . . . . . e150 11.8. Prosthetic Valve Stenosis . . . . . . . . . . . . . . . . . . e151
11.8.1. Diagnosis of Prosthetic Valve Stenosis . . . e151 11.8.2. Intervention for Prosthetic Valve Stenosis . e152
11.9. Prosthetic Valve Regurgitation . . . . . . . . . . . . . e152 11.9.1. Diagnosis of Prosthetic Valve
Regurgitation . . . . . . . . . . . . . . . . . e153 11.9.2. Medical Therapy . . . . . . . . . . . . . . . . . . e154 11.9.3. Intervention . . . . . . . . . . . . . . . . . . . . . e154
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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923e74
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12. Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . e155 12.1. Classification of Endocarditis . . . . . . . . . . . . . . e155 12.2. Diagnosis of IE . . . . . . . . . . . . . . . . . . . . . . . . . e156 12.3. Medical Therapy . . . . . . . . . . . . . . . . . . . . . . . . e160 12.4. Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . e162
13. Pregnancy and VHD . . . . . . . . . . . . . . . . . . . . . . . . . . e165 13.1. Initial Management of Women With VHD
Before and During Pregnancy . . . . . . . . . . . . . e165 13.1.1. Medical Therapy for Women With
VHD Before and During Pregnancy . e166 13.1.2. Intervention for Women With Native
VHD Before and During Pregnancy . e166 13.2. Prosthetic Valves in Pregnant Women . . . . . . e169
13.2.1. Initial Management . . . . . . . . . . . . . . e169 13.2.2. Anticoagulation for Pregnant Women
With Mechanical Prosthetic Heart Valves . . . . . . . . . . . . . . . . . . . . . . . . . . e170
14. Surgical Considerations . . . . . . . . . . . . . . . . . . . . . . . e174 14.1. Evaluation and Management of CAD in
Patients With VHD . . . . . . . . . . . . . . . . . . . . . . e174 14.1.1. Management of CAD in Patients
Undergoing TAVI . . . . . . . . . . . . . . . . e174 14.1.2. Management of CAD in Patients
Undergoing Valve Surgery . . . . . . . . . e176 14.2. Intervention for AF in Patients With VHD . . . e177
15. Noncardiac Surgery in Patients With VHD . . . . . . . . e178 15.1. Diagnosis of Patients With VHD Undergoing
Noncardiac Surgery . . . . . . . . . . . . . . . . . . . . . e178 15.2. Management of the Symptomatic Patient . . . e179 15.3. Management of the Asymptomatic Patient . . e180
16. Evidence Gaps and Future Directions . . . . . . . . . . .…
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