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Aortic Stenosis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Aortic Stenosis

Choice of Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care.	2014 recommendation remains current.
I	B-NR	Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate.	MODIFIED: LOE updated from A to B-NR. Prior recommendations for intervention choice did not specify patient symptoms. The patient population recommended for surgical AVR encompasses both symptomatic and asymptomatic patients who meet an indication for AVR with low-to-intermediate surgical risk. This is opposed to the patient population recommended for TAVR, in whom symptoms are required to be present. Thus, all recommendations for type of intervention now specify the symptomatic status of the patient.
I	A	Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patient specific procedural risks, values, and preferences.	MODIFIED: COR updated from IIa to I, LOE updated from B to A. Longer-term follow-up and additional RCTs have demonstrated that TAVR is equivalent to surgical AVR for severe symptomatic AS when surgical risk is high.
I	A	TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greater than 12 months.	MODIFIED:LOE updated from B to A. Longer-term follow-up from RCTs and additional observational studies has demonstrated the benefit of TAVR in patients with a prohibitive surgical risk.
IIa	B-R	TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS (Stage D) and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences.	NEW: New RCT showed noninferiority of TAVR to surgical AVR in symptomatic patients with severe AS at intermediate surgical risk.
IIb	C	Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR for symptomatic patients with severe AS.	2014 recommendation remains current.
III: No Benefit	C	TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS.	2014 recommendation remains current.

Aortic Stenosis

Aspects to be considered by the Heart Team for decision between SAVR and TAVI in patients at increased surgical risk

	FAVOURS TAVI	FAVOURS SAVR
Clinical Characteristics
STS/EuroSCORE II <4% (logistic EuroSCORE I <10%)		+
STS/EuroSCORE II ≥4% (logistic EuroSCORE I ≥10%)	+
Presence of severe comorbidity (not adequately reflected by scores)	+
Age <75		+
Age ≥75	+
Previous cardiac surgery	+
Frailty	+
Restricted mobility and conditions that may affect the rehabilitation process after the procedure	+
Suspicion of endocarditis		+
Anatomical and technical aspects
Favourable access for transferral TAVI	+
Sequelae of chest radiation	+
Porcelain aorta	+
Presence of intact coronary bypass grafts at risk when sternotomy is performed	+
Expected patients-Prosthesis mismatch	+
Severe chest deformation or scoliosis	+
Short distance between coronary ostia and aortic valve annulus		+
Size of aortic valve annulus out of range for TAVI		+
Valve morphology (bicuspid, degree of calcification, calcification pattern) unfavourable for TAVI		+
Presence of thrombi in aorta or LV		+
Cardiac conditions in addition to aortic stenosis that require consideration for concomitant intervention
Severe CAD requiring revascularisation by CABG		+
Severe primary mitral valve disease, which could be treated surgically		+
Severe tricuspid valve disease		+
Aneurysm of the ascending aorta		+
Septal hypertrophy requiring myectomy		+

Aortic Stenosis

Indications for Intervention in Symptomatic Aortic Stenosis

2012	2017
IIb C	NEW: IIa C
Intervention may be considered in symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow (contractile) reserve.	Intervention should be considered in symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CT calcium scoring confirms severe aortic stenosis.

Indications for Surgery in Asymptomatic Aortic Stenosis

2012	2017
IIb C	NEW: IIa C
Markedly elevated BNP levels.	Markedly elevated BNP levels (>threefold age- and sex-corrected normal range) confirmed by repeated measurements without other explanations.
IIb C	TAKEN OUT
Increase of mean pressure gradient with exercise by >20 mmHg.
IIb C	TAKEN OUT
Excessive LV hypertrophy in the absence of hypertension.
NEW: IIa C Recommendation:
Severe pulmonary hypertension (systolic pulmonary artery pressure at rest >60 mmHg confirmed by invasive measurement) without other explanation.

Indications for Surgery in Severe Aortic Regurgitation and Aortic Root Disease

2017 New Recommendations
NEW: I C Recommendations:
Patients with pliable non-calcified tricuspid or bicuspid valves who have a type I (enlargement of the aortic root with normal cusp motion) or type-II (cusp prolapse) mechanism of aortic regurgitation.
Aortic valve repair, using the reimplantation or remodelling with aortic annuloplasty technique, is recommended in young patients with aortic root dilationand tricuspid aortic valves, when performed by experienced surgeons.
NEW: IIa C Recommendations:
Surgery should be considered in patients who have aortic root disease with maximal ascending aortic diameter: ≥45 mmin patients with a TGFBR1 orTGFBR2 mutation (including Loeys-Dietz syndrome).
A lower threshold of 40 mm may be considered in women with low BSA, in patients with a TGFBR2 mutation, or in patients with severe extra-aortic features.

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendation for Infective Endocarditis (IE) Prophylaxis

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
IIa	C-LD	Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following: 1. Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords. 3. Previous IE. 4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. 5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.	MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.

Recommendation for Anticoagulation for Atrial Fibrillation (AF) in Patients with VHD

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Anticoagulation with a vitamin K antagonist (VKA) is indicated for patients with rheumatic mitral stenosis (MS) and AF.	MODIFIED: VKA as opposed to the direct oral anticoagulants (DOACs) are indicated in patients with AF and rheumatic MS to prevent thromboembolic events. The RCTs of DOACs versus VKA have not included patients with MS. The specific recommendation for anticoagulation of patients with MS is contained in a subsection of the topic on anticoagulation.
I	C-LD	Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or mitral regurgitation.	NEW: Post hoc subgroup analyses of large RCTs comparing DOAC versus warfarin in patients with AF have analyzed patients with native valve disease other than MS and patients who have undergone cardiac surgery. These analyses consistently demonstrated that the risk of stroke is similar to or higher than that of patients without VHD. Thus, the indication for anticoagulation in these patients should follow Guideline Determined Medical Therapy (GDMT) according to the CHA2DS2-VASc score.
IIa	C-LD	It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater.	NEW: Several thousand patients with native VHD (exclusive of more than mild rheumatic MS) have been evaluated in RCTs comparing DOACs versus warfarin. Subgroup analyses have demonstrated that DOACs, when compared with warfarin, appear as effective and safe in patients with VHD as in those without VHD.

Recommendations for Chronic Primary Mitral Regurgitation (MR) Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30%.	2014 recommendation remains current.
I	B	Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2)	2014 recommendation remains current.
I	B	Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet.	2014 recommendation remains current.
I	B	Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished.	2014 recommendation remains current.
I	B	Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications.	2014 recommendation remains current.
IIa	B	Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a Heart Valve Center of Excellence.	2014 recommendation remains current.
IIa	C-LD	Mitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) with a progressive increase in LV size or decrease in ejection fraction (EF) on serial imaging studies.	NEW: Patients with severe MR who reach an EF ≤60% or LVESD ≥40 mm have already developed LV systolic dysfunction, so operating before reaching these parameters, particularly with a progressive increase in LV size or decrease in EF on serial studies, is reasonable.
IIa	B	Mitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) New onset of AF or 2) Resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg).	2014 recommendation remains current.
IIa	C	Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications.	2014 recommendation remains current.
IIb	C	Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30%.	2014 recommendation remains current.
IIb	B	Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF).	2014 recommendation remains current.
IIb	B	Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal Guideline Determined Medical Therapy (GDMT) for heart failure (HF).	2014 recommendation remains current.
III:Harm	B	MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful.	2014 recommendation remains current.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

Indications for Intervention in Asymptomatic Severe Primary Mitral Regurgitation

2012	2017
Pulmonary hypertension on exercise (SPAP ≥60 mmHg at exercise).	TAKEN OUT

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Chronic Secondary Mitral Regurgitation (MR) Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
IIa	C	Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.	2014 recommendation remains current.
IIa	B-R	It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite Guideline Determined Medical Therapy (GDMT) for heart failure (HR).	NEW: An RCT has shown that mitral valve repair is associated with a higher rate of recurrence of moderate or severe MR than that associated with mitral valve replacement (MVR) in patients with severe, symptomatic, ischemic MR, without a difference in mortality rate at 2 years' follow-up.
IIb	B	Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal Guideline Determined Medical Therapy (GDMT) for heart failure (HR).	2014 recommendation remains current.
IIb	B-R	In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain.	MODIFIED: LOE updated from C to B-R. The 2014 recommendation supported mitral valve repair in this group of patients. An RCT showed no clinical benefit of mitral repair in this population of patients, with increased risk of postoperative complications.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

Indications for Mitral Valve Intervention in Secondary Mitral Regurgitation (MR)

2012	2017
IIa C	TAKEN OUT
Surgery should be considered in patients with moderate secondary mitral regurgitation undergoing CABG.
	Additional Statement: The lower thresholds defining severe MR compared to primary MR are based on their association with prognosis. However, it is unclear if prognosis is independently affected by MR compared to LV dysfunction. For isolated mitral valve treatment in secondary MR, thresholds of severity of MR for intervention still need to be validated in clinical trials. So far, no survival benefit has been confirmed for reduction of secondary MR.

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Intervention of Prosthetic Valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C-LD	The choice of type of prosthetic heart valve should be a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risk associated with reintervention.	MODIFIED: LOE updated from C to C-LD. In choosing the type of prosthetic valve, the potential need for and risk of “reoperation” was updated to risk associated with “reintervention.” The use of a transcatheter valve-in-valve procedure may be considered for decision making on the type of valve, but long-term follow-up is not yet available, and some bioprosthetic valves, particularly the smaller-sized valves, will not be suitable for a valve-in-valve replacement. Multiple other factors to be considered in the choice of type of valve for an individual patient; these factors are outlined in the text. More emphasis has been placed on shared decision making between the caregiver and patient.
I	C	A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.	2014 recommendation remains current.
IIa	B-NR	An aortic or mitral mechanical prosthesis is reasonable for patients less than 50 years of age who do not have a contraindication to anticoagulation.	MODIFIED: LOE updated from B to B-NR. The age limit for mechanical prosthesis was lowered from 60 to 50 years of age.
IIa	B-NR	For patients between 50 and 70 years of age, it is reasonable to individualize the choice of either a mechanical or bioprosthetic valve prosthesis on the basis of individual patient factors and preferences, after full discussion of the trade- offs involved.	MODIFIED: Uncertainty exists about the optimum type of prosthesis (mechanical or bioprosthetic) for patients 50 to 70 years of age. There are conflicting data on survival benefit of mechanical versus bioprosthetic valves in this age group, with equivalent stroke and thromboembolic outcomes. Patients receiving a mechanical valve incur greater risk of bleeding, and those undergoing bioprosthetic valve replacement more often require repeat valve surgery.
IIa	B	A bioprosthesis is reasonable for patients more than 70 years of age.	2014 recommendation remains current.
IIb	C	Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered for young patients when VKA anticoagulation is contraindicated or undesirable.	2014 recommendation remains current.

Recommendations for Antithrombotic Therapy for Patients with Prosthetic Heart Valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	A	Anticoagulation with a Vitamin K antagonist (VKA) and INR monitoring is recommended in patients with a mechanical prosthetic valve.	2014 recommendation remains current.
I	B	Anticoagulation with a VKA to achieve an INR of 2.5 is recommended for patients with a mechanical bileaflet or current-generation single-tilting disc AVR and no risk factors for thromboembolism.	2014 recommendation remains current.
I	B	Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage).	2014 recommendation remains current.
I	B	Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical MVR.	2014 recommendation remains current.
I	A	Aspirin 75 mg to 100 mg daily is recommended in addition to anticoagulation with a VKA in patients with a mechanical valve prosthesis.	2014 recommendation remains current.
IIa	B	Aspirin 75 mg to 100 mg per day is reasonable in all patients with a bioprosthetic aortic or mitral valve.	2014 recommendation remains current.
IIa	B-NR	Anticoagulation with a VKA to achieve an INR of 2.5 is reasonable for at least 3 months and for as long as 6 months after surgical bioprosthetic MVR or AVR in patients at low risk of bleeding.	MODIFIED: LOE updated from C to B-NR. Anticoagulation for all surgical tissue prostheses was combined into 1 recommendation, with extension of the duration of anticoagulation up to 6 months. Stroke risk and mortality rate are lower in patients who receive anticoagulation for up to 6 months after implantation of a tissue prosthesis than in those who have do not have anticoagulation. Anticoagulation for a tissue prosthesis is also supported by reports of valve thrombosis for patients undergoing bioprosthetic surgical AVR or MVR, a phenomenon that may be warfarin responsive.
IIb	B-R	A lower target INR of 1.5 to 2.0 may be reasonable in patients with mechanical On-X AVR and no thromboembolic risk factors.	NEW: A lower target INR was added for patients with a mechanical On-X AVR and no thromboembolic risk factors treated with warfarin and low-dose aspirin. A single RCT of lower- versus standard-intensity anticoagulation in patients undergoing On-X AVR showed equivalent outcomes, but the bleeding rate in the control group was unusually high.
IIb	B-NR	Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 months after TAVR in patients at low risk of bleeding	NEW: Studies have shown that valve thrombosis may develop in patients after TAVR, as assessed by multidetector computerized tomographic scanning. This valve thrombosis occurs in patients who received antiplatelet therapy alone but not in patients who were treated with VKA.
IIb	C	Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to life-long aspirin 75 mg to 100 mg daily.	2014 recommendation remains current.
III:Harm	B	Anticoagulant therapy with oral direct thrombin inhibitors or anti-Xa agents should not be used in patients with mechanical valve prostheses.	2014 recommendation remains current.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

New Recommendations

Class	Level	Recommendations
I	B	INR self-management is recommended provided appropriate training and quality control are performed.
IIb	C	The addition of low-dose aspirin (75-100 mg/day) to VKA may be considered in the case of concomitant atherosclerotic disease.
IIa	B	In patients treated with coronary stent implantation, triple therapy with aspirin (75-100 mg/day), clopidogrel (75 mg/day), and VKA should be considered for 1 month, irrespective of the type of stent used and the clinical presentation (i.e. ACS or stable CAD).
IIa	B	Triple therapy comprising aspirin (75-100 mg/day), clopidogrel (75 mg/day), and VKA for longer than 1 month and up to 6 months should be considered in patients with high ischaemic risk due to ACS or other anatomical/procedural characteristics that outweigh the bleeding risk.
IIa	A	Dual therapy comprising VKA and clopidogrel (75 mg/day) should be considered as an alternative to 1-month triple antithrombotic therapy in patients in whom the bleeding risk outweighs the ischaemic risk.
IIa	B	In patients who have undergone PCI, discontinuation of antiplatelet treatment should be considered at 12 months.
IIa	B	In patients requiring aspirin and/or clopidogrel in addition to VKA, the dose intensity of VKA should be carefully regulated with a target INR in the lower part of the recommended target range and a time in therapeutic range > 65-70%.
III	B	The use of NOACs is contra-indicated.

New Recommendations

Class	Level	Recommendations
IIa	C	Dual antiplatelet therapy should be considered for the first 3-6 months after TAVI, followed by lifelong single antiplatelet therapy in patients who do not need oral anticoagulation for other reasons.
IIb	C	Single antiplatelet therapy may be considered after TAVI in the case of high bleeding risk.

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Bridging Therapy for Prosthetic Valves

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	Continuation of Vitamin K antagonists (VKA) anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.	2014 recommendation remains current.
I	C	Temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures.	2014 recommendation remains current.
IIa	C-LD	Bridging anticoagulation therapy during the time interval when the INR is subtherapeutic preoperatively is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention, for patients who are undergoing invasive or surgical procedures with a; 1) Mechanical AVR and any thromboembolic risk factor, 2) Older-generation mechanical AVR, or 3) Mechanical MVR.	MODIFIED: COR updated from I to IIa, LOE updated from C to C-LD. RCTs of bridging anticoagulant therapy versus no bridging therapy for patients with AF who do not have a mechanical heart valve have shown higher risk of bleeding without a change in incidence of thromboembolic events. This may have implications for bridging anticoagulation therapy for patients with prosthetic valves.
IIa	C	Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures	2014 recommendation remains current.

Recommendations for Mechanical Prosthetic Valve Thrombosis Diagnosis and Follow up

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Urgent evaluation with multimodality imaging is indicated in patients with suspected mechanical prosthetic valve thrombosis to assess valvular function, leaflet motion, and the presence and extent of thrombus.	MODIFIED: LOE updated to B-NR. Multiple recommendations for imaging in patients with suspected mechanical prosthetic valve thrombosis were combined into a single recommendation. Multimodality imaging with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), fluoroscopy, and/or computed tomography (CT) scanning may be more effective than one imaging modality alone in detecting and characterizing valve thrombosis. Different imaging modalities are necessary because valve function, leaflet motion, and extent of thrombus should all be evaluated.

Recommendations for Mechanical Prosthetic Valve Thrombosis Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B-NR	Urgent initial treatment with either slow-infusion low-dose fibrinolytic therapy or emergency surgery is recommended for patients with a thrombosed left-sided mechanical prosthetic heart valve presenting with symptoms of valve obstruction.	MODIFIED: LOE updated to B-NR. Multiple recommendations based only on NYHA class symptoms were combined into 1 recommendation. Slow-infusion fibrinolytic therapy has higher success rates and lower complication rates than prior high-dose regimens and is effective in patients previously thought to require urgent surgical intervention. The decision for emergency surgery versus fibrinolytic therapy should be based on multiple factors, including the availability of surgical expertise and the clinical experience with both treatments.

Recommendations for Prosthetic Valve Stenosis

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	C	Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis.	2014 recommendation remains current.
IIa	C-LD	In patients with suspected or confirmed bioprosthetic valve thrombosis who are hemodynamically stable and have no contraindications to anticoagulation, initial treatment with a VKA is reasonable.	NEW: Case series of patients presenting with bioprosthetic valve stenosis have suggested improvement in hemodynamics with VKA treatment because of resolution of thrombus on the valve leaflets.
IIa	B-NR	For severely symptomatic patients with bioprosthetic aortic valve stenosis judged by the heart team to be at high or prohibitive risk of reoperation, and in whom improvement in hemodynamics is anticipated, a transcatheter valve-in-valve procedure is reasonable.	NEW: Registries and case series have reported on the short-term outcomes and complication rates in patients with bioprosthetic AS who have undergone transcatheter valve-in-valve therapy.

Recommendations for Prosthetic Valve Regurgitation

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation.	2014 recommendation remains current.
IIa	C-LD	Surgery is reasonable for asymptomatic patients with severe bioprosthetic regurgitation if operative risk is acceptable.	MODIFIED: LOE updated from C to C-LD. A specific indication for surgery is the presence of severe bioprosthetic regurgitation in a patient with acceptable operative risk. With the new recommendation for valve-in-valve therapy, indications for intervention need to account for patients who would benefit from surgery versus those who would benefit from transcatheter therapy, determined by type of valve, symptomatic status, and risk of reoperation.
IIa	C-LD	Surgery is reasonable for asymptomatic patients with severe bioprosthetic regurgitation if operative risk is acceptable.	MODIFIED: LOE updated from C to C-LD. A specific indication for surgery is the presence of severe bioprosthetic regurgitation in a patient with acceptable operative risk. With the new recommendation for valve-in-valve therapy, indications for intervention need to account for patients who would benefit from surgery versus those who would benefit from transcatheter therapy, determined by type of valve, symptomatic status, and risk of reoperation.
IIa	B	Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure	2014 recommendation remains current.
IIa	B-NR	For severely symptomatic patients with bioprosthetic aortic valve regurgitation judged by the heart team to be at high or prohibitive risk for surgical therapy, in whom improvement in hemodynamics is anticipated, a transcatheter valve-in-valve procedure is reasonable.	NEW: Registries and case series of patients have reported on the short-term outcomes and complication rates for patients with bioprosthetic aortic regurgitation who have undergone transcatheter valve-in-valve replacement.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

New Recommendations

Class	Level	Recommendations
I	C	Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention.
IIa	B-NR	Transcatheter closure may be considered for paravalvular leaks with clinically significant regurgitation in surgical high- risk patients (Heart Team decision).
IIa	C	Transcatheter valve-in-valve implantation in aortic position should be considered by the Heart Team depending on the risk of reoperation and the type and size of prosthesis.

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendations for Infective Endocarditis Intervention

COR	LOE	RECOMMENDATION	COMMENT/RATIONALE
I	B	Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions.	2014 recommendation remains current.
I	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy.	2014 recommendation remains current.
I	C	Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.	2014 recommendation remains current.
I	B	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.	2014 recommendation remains current.
IIa	B	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection.	2014 recommendation remains current.
IIa	C	Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE.	2014 recommendation remains current.
IIa	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.	2014 recommendation remains current.
IIb	B	Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon).	2014 recommendation remains current.
IIb	B-NR	Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage.	NEW: The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
IIb	B-NR	Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable.	NEW: In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.

2017 ESC/EACTS Guidelines for the management of valvular heart disease

Management of Coronary Artery Disease (CAD) in patients with Valvular Heart Disease (VHD)

Recommendations	Class	Level
Diagnosis of Coronary Artery Disease
Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following: • history of cardiovascular disease • suspected myocardial ischaemiad • LV systolic dysfunction • in men >40 years of age and postmenopausal women • one or more cardiovascular risk factors.	I	C
Coronary angiography is recommended in the evaluation of moderate to severe secondary mitral regurgitation.	I	C
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk.	II	A
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk.	IIa	C
Indications for Myocardial Revascularization
CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥70%	I	C
CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥50–70%.	IIa	C
PCI should be considered in patients with a primary indication to undergo TAVI and coronary artery diameter stenosis >70% in proximal segments.	IIa	C
PCI should be considered in patients with a primary indication to undergo transcatheter mitral valve interventions and coronary artery diameter stenosis >70% in proximal segments.	IIa	C
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CT = computed tomography; LV = left ventricular; MSCT = multislice computed tomography; PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease.