2008 Focused Update Incorporated Into the ACC/AHA 2006 ...

1 PRACTICE GUIDELINE2008 Focused Update Incorporated Into theACC/AHA 2006 Guidelines for the Managementof Patients With Valvular Heart DiseaseA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease)Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography andInterventions, and Society of Thoracic Surgeons2006 WritingCommitteeMembersRobert O. Bonow, MD, MACC, FAHA,ChairBlase A. Carabello, MD, FACC, FAHAKanu Chatterjee, MB, FACCA ntonio C. de Leon, JR, MD, FACC, FAHAD avid P. Faxon, MD, FACC, FAHAM ichael D. Freed, MD, FACC, FAHAW illiam H. Gaasch, MD, FACC, FAHAB ruce W. Lytle, MD, FACCRick A. Nishimura, MD, FACC, FAHAP atrick T. O Gara, MD, FACC, FAHAR obert A. O Rourke, MD, MACC, FAHAC atherine M. Otto, MD, FACC, FAHAP ravin M.

2 Shah, MD, MACC, FAHAJack S. Shanewise, MD**Society of Cardiovascular Anesthesiologists Representative2008 FocusedUpdateWritingGroupMembersRick A. Nishimura, MD, FACC, FAHA,ChairBlase A. Carabello, MD, FACC, FAHAD avid P. Faxon, MD, FACC, FAHAM ichael D. Freed, MD, FACC, FAHAB ruce W. Lytle, MD, FACC, FAHAP atrick T. O Gara, MD, FACC, FAHAR obert A. O Rourke, MD, FACC, FAHAP ravin M. Shah, MD, MACC, FAHAThis document was approved by the American College of Cardiology FoundationBoard of Trustees in May 2008 and by the American Heart Association ScienceAdvisory and Coordinating Committee in May American College of Cardiology Foundation requests that this document becited as follows: Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP,Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O Gara PT, O Rourke RA,Otto CM, Shah PM, Shanewise JS. 2008 Focused Update Incorporated into theACC/AHA 2006 guidelines for the management of patients with valvular heartdisease: a report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Writing Committee to Develop Guidelines forthe Management of Patients With Valvular Heart Disease.)

3 J Am Coll Cardiol2008;52:e1 article is copublished in the September 23, 2008, issue : This document is available on the World Wide Web sites of the AmericanCollege of Cardiology ( ) and the American Heart Association ( ). For copies of this document, please contact Elsevier Department, fax (212) 633-3820, Modification, alteration, enhancement and/or distribution of thisdocument are not permitted without the express permission of the American Collegeof Cardiology Foundation or the American Heart Association. Please contactElsevier s permission department of the American College of CardiologyVol. 52, No. 13, 2008 2008 by the American College of Cardiology Foundation and the American Heart Association, 0735-1097/08/$ by Elsevier C. Smith, JR, MD, FACC, FAHA,ChairAlice K. Jacobs, MD, FACC, FAHA,Vice-ChairChristopher E. Buller, MD, FACCMark A. Creager, MD, FACC, FAHAS teven M.

4 Ettinger, MD, FACCD avid P. Faxon, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA Harlan M. Krumholz, MD, FACC, FAHAF rederick G. Kushner, MD, FACC, FAHAB ruce W. Lytle, MD, FACC, FAHA Rick A. Nishimura, MD, FACC, FAHAR ichard L. Page, MD, FACC, FAHALynn G. Tarkington, RNClyde W. Yancy, JR, MD, FACC, FAHA Former Task Force member during this writing effortTABLE OF CONTENTSPREAMBLE (UPDATED)..e51. Evidence Review (UPDATED).. Scope of the Document (UPDATED).. Review and Approval (NEW)..e82. GENERAL Evaluation of the Patient With a Introduction(UPDATED).. Classification of DYNAMIC CARDIAC OTHER PHYSICAL ASSOCIATED and Chest Cardiac Exercise Approach to the Valve Disease Severity Endocarditis and Rheumatic Fever Prophylaxis(UPDATED).. Endocarditis Prophylaxis(UPDATED)..e13 Table 5(DELETED)Table 6 (UPDATED)Table 7 (UPDATED)Table 8(DELETED) Rheumatic Fever GENERAL PRIMARY SECONDARY SPECIFIC VALVE Aortic GRADING THE DEGREE OF Natural Management of the Asymptomatic ECHOCARDIOGRAPHY (IMAGING, SPECTRAL, ANDCOLOR DOPPLER) IN AORTIC EXERCISE SERIAL MEDICAL THERAPY(UPDATED).

5 PHYSICAL ACTIVITY AND Indications for Cardiac Low-Flow/Low-Gradient Aortic Indications for Aortic Valve SYMPTOMATIC ASYMPTOMATIC PATIENTS UNDERGOING CORONARY ARTERY BYPASS OROTHER CARDIAC Aortic Balloon Medical Therapy for the Inoperable Evaluation After Aortic Valve Special Considerations in the Aortic Acute Aortic Chronic Aortic NATURAL PATIENTS WITH NORMAL LEFTVENTRICULAR PATIENTS WITH DEPRESSED DIAGNOSIS AND INITIAL MEDICAL PHYSICAL ACTIVITY AND SERIAL INDICATIONS FOR CARDIAC INDICATIONS FOR AORTIC VALVE REPLACEMENT ORAORTIC VALVE PATIENTS WITH NORMAL LEFTVENTRICULAR SYSTOLIC PATIENTS WITH LEFT Concomitant Aortic Root Evaluation of Patients After Aortic Special Considerations in the Vol. 52, No. 13, 2008 ACC/AHA VHD Guidelines: 2008 Focused Update IncorporatedSeptember 23, 2008:e1 Bicuspid Aortic Valve With Dilated Mitral Pathophysiology and Natural Indications for Echocardiography in Medical MEDICAL THERAPY: GENERAL(UPDATED).

6 MEDICAL THERAPY: ATRIAL THERAPY: PREVENTION OF Recommendations Regarding Physical Activityand Serial Evaluation of the Symptomatic for Invasive Indications for Percutaneous Mitral Indications for Surgery for Mitral Management of Patients After Valvotomy Special PREGNANT OLDER Mitral Valve Pathophysiology and Natural Evaluation and Management of theAsymptomatic Patient(UPDATED).. Evaluation and Management of theSymptomatic Patient(UPDATED).. Surgical Mitral Acute Severe Mitral MEDICAL Chronic Asymptomatic Mitral PATHOPHYSIOLOGY AND NATURAL INDICATIONS FOR TRANSTHORACIC FOR TRANSESOPHAGEAL SERIAL GUIDELINES FOR PHYSICAL ACTIVITY AND MEDICAL INDICATIONS FOR CARDIAC Indications for TYPES OF INDICATIONS FOR MITRAL VALVE PATIENTS WITH NORMAL LEFTVENTRICULAR OR SYMPTOMATIC PATIENTS WITHLEFT VENTRICULAR PATIENTS WITH NORMAL LEFTVENTRICULAR Ischemic Mitral Evaluation of Patients After Mitral ValveReplacement or Special Considerations in the Multiple Valve Mixed Single Valve AND DOPPLER Mitral Stenosis and Aortic Combined Mitral Stenosis and Combined Mitral Regurgitation and DIAGNOSIS AND Combined Mitral Stenosis and Aortic DIAGNOSIS AND Aortic Stenosis and Mitral DIAGNOSIS AND Tricuspid Valve Drug-Related Valvular Heart

7 Radiation Heart EVALUATION AND MANAGEMENT OF Antimicrobial Culture-Negative Endocarditis in HIV-Seropositive Indications for Echocardiography inSuspected or Known Echocardiography in Echocardiography Outpatient Indications for Surgery in Patients WithAcute Infective Surgery for Native Valve Surgery for Prosthetic Valve MANAGEMENT OF VALVULAR DISEASE Physiological Changes of Physical General Management Specific Mitral Mitral Aortic Aortic Pulmonic Tricuspid Valve Marfan Endocarditis Prophylaxis (UPDATED).. Cardiac Valve Vol. 52, No. 13, 2008 Bonowet 23, 2008:e1 142 ACC/AHA VHD Guidelines: 2008 Focused Update Anticoagulation During Unfractionated Low-Molecular-Weight Selection of Anticoagulation Regimen in PregnantPatients With Mechanical Prosthetic of Valve Prostheses in Young MANAGEMENT OF CONGENITAL VALVULAR HEARTDISEASE IN ADOLESCENTS AND YOUNG ADULTS(UPDATED).

8 Aortic Evaluation of Asymptomatic Adolescents orYoung Adults With Aortic Indications for Aortic Balloon Valvotomy inAdolescents and Young Aortic Mitral Mitral Tricuspid Valve Evaluation of Tricuspid Valve Disease inAdolescents and Young Indications for Intervention in Pulmonic Evaluation of Pulmonic Stenosis in Adolescentsand Young Indications for Balloon Valvotomy in PulmonicStenosis(UPDATED).. Pulmonary SURGICAL American Association for Thoracic Surgery/Society of Thoracic Surgeons Guidelines forClinical Reporting of Heart Aortic Valve Risks and Strategies in Aortic Valve Mechanical Aortic Valve ANTITHROMBOTIC THERAPY FOR PATIENTS WITH AORTICMECHANICAL HEART Stented and Nonstented VALVE REPLACEMENT WITH STENTED VALVE REPLACEMENT WITH Aortic Valve Pulmonic Valve Aortic Valve Left Ventricle to Descending Aorta Comparative Trials and Selection of AorticValve Major Criteria for Aortic Valve Mitral Valve Mitral Valve MYXOMATOUS MITRAL RHEUMATIC HEART ISCHEMIC MITRAL VALVE MITRAL VALVE Mitral Valve Prostheses (Mechanical orBioprostheses).

9 SELECTION OF A MITRAL VALVE CHOICE OF MITRAL VALVE Tricuspid Valve Selection for Women of Childbearing INTRAOPERATIVE Specific Valve Aortic Aortic Mitral Mitral Tricuspid Tricuspid Pulmonic Valve Specific Clinical Previously Undetected Aortic Stenosis Previously Undetected Mitral RegurgitationDuring MANAGEMENT OF PATIENTS WITH PROSTHETICHEART Antibiotic Infective Recurrence of Rheumatic Antithrombotic Mechanical Biological Embolic Events During Adequate Excessive Bridging Therapy in Patients WithMechanical Valves Who Require Interruptionof Warfarin Therapy for Noncardiac Surgery,Invasive Procedures, or Dental Antithrombotic Therapy in Patients Who NeedCardiac Thrombosis of Prosthetic Heart Follow-Up First Outpatient Postoperative Visits in Patients Visits in Patients With Reoperation to Replace a Prosthetic EVALUATION AND TREATMENT OF CORONARYARTERY DISEASE IN PATIENTS WITH VALVULARHEART Probability of Coronary Artery Disease inPatients With Valvular Heart Diagnosis of Coronary Artery Treatment of Coronary Artery Disease atthe Time of Aortic Valve Aortic Valve Replacement in PatientsUndergoing Coronary Artery Bypass Management of Concomitant MV Diseaseand Coronary Artery Vol.

10 52, No. 13, 2008 ACC/AHA VHD Guidelines: 2008 Focused Update IncorporatedSeptember 23, 2008:e1 142 APPENDIX 4 (NEW) ..e140 APPENDIX 5 (NEW) ..e141 PREAMBLE (UPDATED)It is important that the medical profession play a significantrole in critically evaluating the use of diagnostic proceduresand therapies as they are introduced in the detection,management, or prevention of disease states. Rigorous andexpert analysis of the available data documenting the abso-lute and relative benefits and risks of those procedures andtherapies can produce helpful guidelines that improve theeffectiveness of care, optimize patient outcomes, and favor-ably affect the overall cost of care by focusing resources onthe most effective American College of Cardiology (ACC) and theAmerican Heart Association (AHA) have jointly engagedin the production of such guidelines in the area of cardio-vascular disease since 1980.