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{| class="infobox" style="float:right;"
{{Mitral regurgitation}}
{{CMG}}; {{AE}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]; {{Rim}}
 
==Overview==
[[Cardiac catheterization]] is useful to evaluate mitral regurgitation when the results of the non-invasive testing are insufficient.  In addition, [[cardiac catheterization]] might be performed when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or [[pulmonary hypertension]] as the cause of the patient's symptoms. [[Coronary angiography]] should be considered prior to [[mitral regurgitation surgery|mitral valve surgery]] among patients with risk factors of [[coronary artery disease]] among whom the underlying etiology of mitral regurgitation is suspected to be of [[ischemia|ischemic]] origin.
 
==Cardiac Catheterization==
[[Cardiac catheterization]] is useful to evaluate mitral regurgitation when the results of the non-invasive testing are insufficient.  In addition, [[cardiac catheterization]] might be performed when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or [[pulmonary hypertension]] as the cause of the patient's symptoms. [[Coronary angiography]] should be considered prior to [[mitral regurgitation surgery|mitral valve surgery]] among patients with [[risk factors]] of [[coronary artery disease]] among whom the underlying etiology of mitral regurgitation is suspected to be of [[ischemia|ischemic]] origin.<ref name="pmid16875962">{{cite journal| author=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). Society of Cardiovascular Anesthesiologists. Bonow RO, Carabello BA, Chatterjee K et al.| title=ACC/AHA 2006 guidelines 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 (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 3 | pages= e1-148 | pmid=16875962 | doi=10.1016/j.jacc.2006.05.021 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16875962  }} </ref><ref name="pmid22547754">{{cite journal| author=Nishimura RA, Carabello BA| title=Hemodynamics in the cardiac catheterization laboratory of the 21st century. | journal=Circulation | year= 2012 | volume= 125 | issue= 17 | pages= 2138-50 | pmid=22547754 | doi=10.1161/CIRCULATIONAHA.111.060319 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22547754  }} </ref><ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
 
* [[Left ventriculography]] and hemodynamic assessment by cardiac catheterization can be used to evaluate mitral regurgitation when the results of the non-invasive testing are inconclusive. 
* [[Cardiac catheterization]] should also be considered when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or [[pulmonary hypertension]] as the cause of the patient's symptoms.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>
 
* Both the [[RAO]] and [[LAO Cranial|LAO]] cranial projections can be used during [[left ventriculography]] to identify significant mitral regurgitation.
* Grading the amount of regurgitation is based on the amount of opacification of the [[left atrium]] compared to the [[left ventricle]], the atrial size, and the number of cycles required for maximal opacification of the [[left atrium]].
* Elevation of [[left atrial]] pressure in acute regurgitation and dilation of the [[left atrium]] from chronic regurgitation can both interfere with the use of this grading system.
* The grading of mitral regurgitation based on the [[left ventriculography]] findings is as follows:
**'''+1''': There is brief and incomplete atrial opacification over several cycles. The dye clears rapidly. There is no atrial enlargement.
**'''+2:''' There is moderate opacification of the [[left atrium]] with each cycle. The opacification is never greater than [[left ventricular]] opacification. There is no significant [[left atrial]] enlargement.
**'''+3:''' There is atrial opacification equal to ventricular opacification.  There is delayed clearing of atria over several cycles. There is significant enlargement of the left atrium.
**'''+4:''' There is left atrial opacification which is immediate and is greater than that of the [[left ventricle]]. There is severe enlargement of the [[left atrium]]. There is opacification of the [[pulmonary vein]]s.
 
 
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
|-
| [[File:Critical_Pathways.gif|88px|link=Mitral regurgitation critical pathways]]|| <br> || <br>
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]]  ([[ ESC  guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]]<br>
* Suspected [[myocardial ischemia]]<br>
* [[Left ventricular]] [[systolic dysfunction]]<br>
* In men >40 years of age and [[postmenopausal]] [[women]]<br>
* One or more [[cardiovascular]] [[risk factors]]<br>
* Evaluation of severe [[mitral regurgitation]] <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]]  ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70%<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments<br>
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments<br>
 
|}
<span style="font-size:85%">'''Abbreviations:'''
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]
 
</span>
<br>
 
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
 
== 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<ref name="pmid33332150">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=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. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==
 
=== Recommendation for Diagnostic Testing: Exercise Testing for Chronic Primary MR Referenced studies that support the recommendation are summarized in Online Data Supplement ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |1.   In patients with primary MR (Stages B and C) and symptoms that might be attributable to MR, hemodynamic exercise testing using Doppler echocardiography or cardiac catheterization or cardiopulmonary exercise testing is reasonable''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
|}
{{Mitral regurgitation}}
{{CMG}}; {{AE}} [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]] [mailto:msbeih@wikidoc.org]


==Overview==
=== Recommendations for Diagnosis of Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement ===
In patients with mitral regurgitation who have risk factors for coronary artery disease, such as advanced age, hypercholesterolemia, and hypertension, or when there is a suspicion that mitral regurgitation is ischemic in origin, coronary angiography should be performed before surgery.
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |2.   In patients with chronic secondary MR (Stages B to D), noninvasive imaging (stress nuclear/PET, CMR, or stress echocardiography), coronary CT angiography, or coronary arteriography is useful to establish etiology of MR and to assess myocardial viability.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''
|}


==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==
==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==
Line 65: Line 148:
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Left ventriculography]] and hemodynamic measurements are not indicated in patients with [[MR]] in whom valve surgery is not contemplated.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Left ventriculography]] and hemodynamic measurements are not indicated in patients with [[MR]] in whom valve surgery is not contemplated.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
|}
==Sources==
*2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (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 and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>


==References==
==References==

Latest revision as of 23:33, 7 December 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed A. Sbeih, M.D. [2]; Rim Halaby, M.D. [3]

Overview

Cardiac catheterization is useful to evaluate mitral regurgitation when the results of the non-invasive testing are insufficient. In addition, cardiac catheterization might be performed when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or pulmonary hypertension as the cause of the patient's symptoms. Coronary angiography should be considered prior to mitral valve surgery among patients with risk factors of coronary artery disease among whom the underlying etiology of mitral regurgitation is suspected to be of ischemic origin.

Cardiac Catheterization

Cardiac catheterization is useful to evaluate mitral regurgitation when the results of the non-invasive testing are insufficient. In addition, cardiac catheterization might be performed when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or pulmonary hypertension as the cause of the patient's symptoms. Coronary angiography should be considered prior to mitral valve surgery among patients with risk factors of coronary artery disease among whom the underlying etiology of mitral regurgitation is suspected to be of ischemic origin.[1][2][3]

  • Left ventriculography and hemodynamic assessment by cardiac catheterization can be used to evaluate mitral regurgitation when the results of the non-invasive testing are inconclusive.
  • Cardiac catheterization should also be considered when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or pulmonary hypertension as the cause of the patient's symptoms.[3]
  • Both the RAO and LAO cranial projections can be used during left ventriculography to identify significant mitral regurgitation.
  • Grading the amount of regurgitation is based on the amount of opacification of the left atrium compared to the left ventricle, the atrial size, and the number of cycles required for maximal opacification of the left atrium.
  • Elevation of left atrial pressure in acute regurgitation and dilation of the left atrium from chronic regurgitation can both interfere with the use of this grading system.
  • The grading of mitral regurgitation based on the left ventriculography findings is as follows:
    • +1: There is brief and incomplete atrial opacification over several cycles. The dye clears rapidly. There is no atrial enlargement.
    • +2: There is moderate opacification of the left atrium with each cycle. The opacification is never greater than left ventricular opacification. There is no significant left atrial enlargement.
    • +3: There is atrial opacification equal to ventricular opacification. There is delayed clearing of atria over several cycles. There is significant enlargement of the left atrium.
    • +4: There is left atrial opacification which is immediate and is greater than that of the left ventricle. There is severe enlargement of the left atrium. There is opacification of the pulmonary veins.


Recommendations for management of CAD in valvular heart disease
Coronary angiography (Class I, Level of Evidence C):

❑ Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following:

Coronary CT angiography (Class I, Level of Evidence C):

❑ Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD

CABG:(Class I, Level of Evidence C) :

❑ CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70%

CABG : (Class IIa, Level of Evidence C)

❑ CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70%

PCI : (Class IIa, Level of Evidence C)

❑ PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments
❑ PCI is recommended in patients undergoing transcatheter mitral valve intervention and coronary artery diameter stenosis > 70% in proximal segments

Abbreviations: CAD: Coronary artery disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; TAVI:Transcatheter aortic valve implantation; VHD:Valvular heart disease


The above table adopted from 2021 ESC Guideline[4]

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[5]

Recommendation for Diagnostic Testing: Exercise Testing for Chronic Primary MR Referenced studies that support the recommendation are summarized in Online Data Supplement

Class IIa
1.   In patients with primary MR (Stages B and C) and symptoms that might be attributable to MR, hemodynamic exercise testing using Doppler echocardiography or cardiac catheterization or cardiopulmonary exercise testing is reasonable(Level of Evidence: B-NR)

Recommendations for Diagnosis of Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement

Class I
2.   In patients with chronic secondary MR (Stages B to D), noninvasive imaging (stress nuclear/PET, CMR, or stress echocardiography), coronary CT angiography, or coronary arteriography is useful to establish etiology of MR and to assess myocardial viability.(Level of Evidence: C-EO)

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary[3]

Recommendations for Chronic Primary Mitral Regurgitation

Cardiac Catheterization Recommendations

Class IIa
"1. Exercise hemodynamics with either doppler echocardiography or cardiac catheterization is reasonable in symptomatic patients with chronic primary mitral regurgitation (MR) where there is a discrepancy between symptoms and the severity of MR at rest (stages B and C). (Level of Evidence: B) "

Exercise Testing Recommendations

Class IIa
"1. Exercise treadmill testing can be useful in patients with chronic primary mitral regurgitation to establish symptom status and exercise tolerance (stages B and C). (Level of Evidence: C"

Recommendations for Chronic Secondary Mitral Regurgitation

Class I
"1.Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR. (Level of Evidence: C)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [6]

Cardiac Catheterization Indications (DO NOT EDIT) [6]

Class I
"1. Left ventriculography and hemodynamic measurements are indicated when noninvasive tests are inconclusive regarding severity of MR, LV function, or the need for surgery.(Level of Evidence: C) "
"2. Hemodynamic measurements are indicated when pulmonary artery pressure is out of proportion to the severity of MR as assessed by noninvasive testing.(Level of Evidence: C) "
"3. Left ventriculography and hemodynamic measurements are indicated when there is a discrepancy between clinical and noninvasive findings regarding severity of MR.(Level of Evidence: C) "
"4. Coronary angiography is indicated before mitral valve repair or mitral valve replacement in patients at risk for CAD.(Level of Evidence: C) "
Class III
"1. Left ventriculography and hemodynamic measurements are not indicated in patients with MR in whom valve surgery is not contemplated.(Level of Evidence: C) "

References

  1. ↑ 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). Society of Cardiovascular Anesthesiologists. Bonow RO, Carabello BA, Chatterjee K; et al. (2006). "ACC/AHA 2006 guidelines 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 (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". J Am Coll Cardiol. 48 (3): e1–148. doi:10.1016/j.jacc.2006.05.021. PMID 16875962.
  2. ↑ Nishimura RA, Carabello BA (2012). "Hemodynamics in the cardiac catheterization laboratory of the 21st century". Circulation. 125 (17): 2138–50. doi:10.1161/CIRCULATIONAHA.111.060319. PMID 22547754.
  3. ↑ 3.0 3.1 3.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  4. ↑ Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
  5. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "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. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  6. ↑ 6.0 6.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (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 and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)

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