Pulmonic regurgitation classification: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Pulmonic regurgitation}} | {{Pulmonic regurgitation}} | ||
{{CMG}}{{AE}} {{AKI}}, {{AA}} | {{CMG}}{{AE}} {{AKI}}, {{AA}}, {{JA}} | ||
==Overview== | ==Overview== | ||
[[Pulmonary valve]] [[regurgitation]] may be classified according to [[ | [[Pulmonary valve]] [[regurgitation]] ([[PR]]) may be classified according to [[etiology]] of the [[regurgitation|regurgitant flow]], severity of the [[disease]] and chronicity. Based on the [[etiology]] of the [[regurgitation|regurgitant flow]], [[PR]] may be classified into primary and secondary/ functional types. The severity of the [[disease]] may classify into mild, moderate and severe [[disease]]. New York Heart Association's (NYHA) functional classification helps to gauge the severity of the [[heart failure]] which is a complication of [[PR]]. The severity of [[PR]] can be assessed by utilizing the American Heart Association and American College of Cardiology (AHA/ACC) staging of [[valvular heart disease]] (VHD). | ||
==Classification== | ==Classification== | ||
[[Pulmonary | [[Pulmonary regurgitation]] (PR) may be classified into subtypes based on the [[etiology]] of the [[regurgitation|regurgitant flow]], severity of the disease and chronicity.<ref name="ZoghbiAdams2017">{{cite journal|last1=Zoghbi|first1=William A.|last2=Adams|first2=David|last3=Bonow|first3=Robert O.|last4=Enriquez-Sarano|first4=Maurice|last5=Foster|first5=Elyse|last6=Grayburn|first6=Paul A.|last7=Hahn|first7=Rebecca T.|last8=Han|first8=Yuchi|last9=Hung|first9=Judy|last10=Lang|first10=Roberto M.|last11=Little|first11=Stephen H.|last12=Shah|first12=Dipan J.|last13=Shernan|first13=Stanton|last14=Thavendiranathan|first14=Paaladinesh|last15=Thomas|first15=James D.|last16=Weissman|first16=Neil J.|title=Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation|journal=Journal of the American Society of Echocardiography|volume=30|issue=4|year=2017|pages=303–371|issn=08947317|doi=10.1016/j.echo.2017.01.007}}</ref> | ||
===Based on the Etiology=== | ===Based on the Etiology=== | ||
[[Pulmonary | [[Pulmonary regurgitation]] (PR) may be classified into two subtypes based on either intrinsic or extrinsic factors involved in the development of the [[disease]]: | ||
*'''Primary pulmonary regurgitation''' | *'''Primary pulmonary regurgitation'''<ref name="pmid17569817">{{cite journal| author=Chaturvedi RR, Redington AN| title=Pulmonary regurgitation in congenital heart disease. | journal=Heart | year= 2007 | volume= 93 | issue= 7 | pages= 880-9 | pmid=17569817 | doi=10.1136/hrt.2005.075234 | pmc=1994453 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17569817 }} </ref>: The [[pulmonary valve|valvular]] pathology is the cause of [[PR]]. Isolated PR is very rare and is most commonly associated with other [[congenital heart diseases]]. | ||
*'''Secondary or functional pulmonary regurgitation'''<ref name="pmid23922549">{{cite journal| author=Di Lullo L, Floccari F, Rivera R, Barbera V, Granata A, Otranto G et al.| title=Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists. | journal=Cardiorenal Med | year= 2013 | volume= 3 | issue= 2 | pages= 96-103 | pmid=23922549 | doi=10.1159/000350952 | pmc=3721135 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23922549 }} </ref><ref name="FrigiolaGiardini2012">{{cite journal|last1=Frigiola|first1=A.|last2=Giardini|first2=A.|last3=Taylor|first3=A.|last4=Tsang|first4=V.|last5=Derrick|first5=G.|last6=Khambadkone|first6=S.|last7=Walker|first7=F.|last8=Cullen|first8=S.|last9=Bonhoeffer|first9=P.|last10=Marek|first10=J.|title=Echocardiographic assessment of diastolic biventricular properties in patients operated for severe pulmonary regurgitation and association with exercise capacity|journal=European Heart Journal - Cardiovascular Imaging|volume=13|issue=8|year=2012|pages=697–702|issn=2047-2404|doi=10.1093/ehjci/jes002}}</ref><ref>{{cite book | last = Fauci | first = Anthony | title = Harrison's principles of internal medicine | publisher = McGraw-Hill Medical | location = New York | year = 2008 | isbn = 978-0071466332 }}</ref>: The [[pulmonary valve]] function is normal. Conditions such as [[pulmonary hypertension]] and [[pulmonary artery]] [[aneurysm]] cause dilation of the [[valve annulus]] resulting in [[regurgitation]]. Secondary [[PR]] is more common than primary [[PR]]. | |||
===Based on the Severity=== | ===Based on the Severity=== | ||
[[Pulmonary valve]] [[regurgitation]] | [[Pulmonary valve]] [[regurgitation]] may be classified into three categories based on the severity of the [[regurgitation|regurgitant flow]]:<ref name="pmid20620859">{{cite journal| author=Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.| title=Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 7 | pages= 685-713; quiz 786-8 | pmid=20620859 | doi=10.1016/j.echo.2010.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620859 }} </ref><ref name="LancellottiTribouilloy2010">{{cite journal|last1=Lancellotti|first1=P.|last2=Tribouilloy|first2=C.|last3=Hagendorff|first3=A.|last4=Moura|first4=L.|last5=Popescu|first5=B. A.|last6=Agricola|first6=E.|last7=Monin|first7=J. L.|last8=Pierard|first8=L. A.|last9=Badano|first9=L.|last10=Zamorano|first10=J. L.|last11=Sicari|first11=R.|last12=Vahanian|first12=A.|last13=Roelandt|first13=J. R. T. C.|title=European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)|journal=European Journal of Echocardiography|volume=11|issue=3|year=2010|pages=223–244|issn=1525-2167|doi=10.1093/ejechocard/jeq030}}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|'''Severity'''}} | ! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|'''Severity'''}} | ||
| Line 36: | Line 37: | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: center;" | Post procedure (such as valvulotomy) or <br> anatomic abnormalities of the [[valve]] | | style="padding: 0 5px; background: #F5F5F5; text-align: center;" | Post procedure (such as valvulotomy) or <br> anatomic abnormalities of the [[valve]] | ||
|}<br /> | |}<br /> | ||
===Based on the Chronicity=== | |||
[[Pulmonic regurgitation]] (PR) may be classified into two subtypes based on the chronicity of the [[disease]]. [[Chronic]] diseases are broadly defined as conditions that last 1 year or more.<ref name="urlAbout Chronic Diseases | CDC">{{cite web |url=https://www.cdc.gov/chronicdisease/about/index.htm#:~:text=Chronic%20diseases%20are%20defined%20broadly,disability%20in%20the%20United%20States. |title=About Chronic Diseases | CDC |format= |work= |accessdate=}}</ref> | |||
*'''Acute [[PR]]'''<ref name="DePaceNestico1984">{{cite journal|last1=DePace|first1=Nicholas L|last2=Nestico|first2=Pasquale F|last3=Iskandrian|first3=Abdulmassih S|last4=Morganroth|first4=Joel|title=Acute severe pulmonic valve regurgitation: Pathophysiology, diagnosis, and treatment|journal=American Heart Journal|volume=108|issue=3|year=1984|pages=567–573|issn=00028703|doi=10.1016/0002-8703(84)90425-3}}</ref>: | |||
**Severe acute [[PR]] may occur due to [[infective endocarditis]] and [[chest trauma|blunt chest trauma]] with direct [[injury]] to [[heart]] structures specially among [[patients]] with abnormal dilation of [[pulmonary arteries]]. | |||
**Acute [[PR]] due to [[infective endocarditis|endocarditis]] may be ''low or high-pressure type''. A ''low-pressure'' [[PR]] may progress to ''high-pressure'' [[PR]]. | |||
*'''Chronic [[PR]]''': | |||
** ''Chronic low-pressure [[PR]]''<ref name="DePaceNestico1984">{{cite journal|last1=DePace|first1=Nicholas L|last2=Nestico|first2=Pasquale F|last3=Iskandrian|first3=Abdulmassih S|last4=Morganroth|first4=Joel|title=Acute severe pulmonic valve regurgitation: Pathophysiology, diagnosis, and treatment|journal=American Heart Journal|volume=108|issue=3|year=1984|pages=567–573|issn=00028703|doi=10.1016/0002-8703(84)90425-3}}</ref>: | |||
**#[[Congenital]] causes include [[pulmonic valve]] abnormalities and [[idiopathic]] dilatation of the [[pulmonary artery]] (IDPA). | |||
**#Acquired cause include post [[pulmonary valve stenosis]] repair or [[TOF]] repair, [[tertiary syphilis]], chronic [[endocarditis]], [[rheumatic heart disease]], [[carcinoid syndrome|carcinoid heart disease]], and [[Marfan’s syndrome]]. | |||
**''Chronic high-pressure [[PR]]'': Causes include primary and secondary [[pulmonary hypertension]]. | |||
===Other Classifications=== | |||
*According to the 2018 ACHD guidelines, moderate or greater [[pulmonary valve regurgitation]] lies under ''moderate complexity'' according to ACHD (adult congenital heart disease) anatomic and physiological classification.<ref name="StoutDaniels2019">{{cite journal|last1=Stout|first1=Karen K.|last2=Daniels|first2=Curt J.|last3=Aboulhosn|first3=Jamil A.|last4=Bozkurt|first4=Biykem|last5=Broberg|first5=Craig S.|last6=Colman|first6=Jack M.|last7=Crumb|first7=Stephen R.|last8=Dearani|first8=Joseph A.|last9=Fuller|first9=Stephanie|last10=Gurvitz|first10=Michelle|last11=Khairy|first11=Paul|last12=Landzberg|first12=Michael J.|last13=Saidi|first13=Arwa|last14=Valente|first14=Anne Marie|last15=Van Hare|first15=George F.|title=2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines|journal=Circulation|volume=139|issue=14|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000602}}</ref> | |||
*[[Pulmonic regurgitation]] may lead to right and eventually left [[heart failure]]. New York Heart Association's (NYHA) functional classification helps to guage the severity of the [[heart failure]] via physical [[disability]] of the [[patient]]. To read more about the NYHA classification [[New york heart association functional classification|click here]]. | |||
===Staging=== | |||
The staging described is based on 2014 According to the American Heart Association and American College of Cardiology (AHA/ACC) [[valvular heart disease]] 2014 guidelines. | |||
====Staging of [[valvular heart disease]] (VHD)<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=Rick A.|last2=Otto|first2=Catherine M.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Guyton|first6=Robert A.|last7=O’Gara|first7=Patrick T.|last8=Ruiz|first8=Carlos E.|last9=Skubas|first9=Nikolaos J.|last10=Sorajja|first10=Paul|last11=Sundt|first11=Thoralf M.|last12=Thomas|first12=James D.|title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary|journal=Circulation|volume=129|issue=23|year=2014|pages=2440–2492|issn=0009-7322|doi=10.1161/CIR.0000000000000029}}</ref>==== | |||
Staging is based on the progression of the [[disease]]. Although the staging has not been specified for [[PR]], it is a useful tool to access the disease course. | |||
*''Stage A'' (at risk) : [[Patient]] has developed risk factors for [[valvular heart disease|VHD]]. Asymptomatic [[patient]]. Development of [[pulmonary hypertension]] (PAH) as a risk for [[PR]] is an example. | |||
*''Stage B'' (progressive): [[Patient]] has developed mild-moderate [[valvular heart disease|VHD]]. Asymptomatic [[patient]]. | |||
*''Stage C'' (asymptomatic severe): [[Patient]] has developed severe [[valvular heart disease|VHD]]. Asymptomatic [[patient]] but exercise test can confirm [[symptom]] status. | |||
*''Stage D'' (symptomatic severe): [[Patient]] has developed severe [[valvular heart disease|VHD]]. Symptomatic [[patient]] such as [[heart failure]] symptoms. | |||
=== | ====Staging of severe [[PR]]<ref name="pmid24603191">{{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: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2014 | volume= 63 | issue= 22 | pages= e57-185 | pmid=24603191 | doi=10.1016/j.jacc.2014.02.536 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24603191 }} </ref>==== | ||
{| class="wikitable" | |||
*[[ | ! style="width: 200px; background: #4479BA;"|Stage | ||
! style="width: 200px; background: #4479BA;"|Definition | |||
! style="width: 200px; background: #4479BA;"|Pulmonary Valve | |||
Anatomy | |||
! style="width: 200px; background: #4479BA;"|Valve Hemodynamics | |||
! style="width: 200px; background: #4479BA;"|Hemodynamic Consequences | |||
! style="width: 200px; background: #4479BA;"|Symptoms | |||
|- | |||
|C,D | |||
|Severe [[PR]] | |||
| | |||
*Distorted or absent leaflets | |||
*Annular dilation | |||
| | |||
*Color jet fills [[Ventricular outflow tract|right ventricular outlet tract]] | |||
*CW jet density and contour: dense laminar flow with steep deceleration slope; may terminate abruptly | |||
| | |||
*Paradoxical [[Interventricular septum|septal]] motion ([[volume overload]] pattern) | |||
*[[Right ventricle| Right ventricular]] enlargement | |||
| | |||
*None or variable<br> | |||
*Dependent on the cause of [[PR]] and [[right ventricle|right ventricular]] function | |||
|} | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Latest revision as of 15:24, 3 August 2020
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Pulmonic regurgitation Microchapters |
|
Diagnosis |
|---|
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2], Aysha Anwar, M.B.B.S[3], Javaria Anwer M.D.[4]
Overview
Pulmonary valve regurgitation (PR) may be classified according to etiology of the regurgitant flow, severity of the disease and chronicity. Based on the etiology of the regurgitant flow, PR may be classified into primary and secondary/ functional types. The severity of the disease may classify into mild, moderate and severe disease. New York Heart Association's (NYHA) functional classification helps to gauge the severity of the heart failure which is a complication of PR. The severity of PR can be assessed by utilizing the American Heart Association and American College of Cardiology (AHA/ACC) staging of valvular heart disease (VHD).
Classification
Pulmonary regurgitation (PR) may be classified into subtypes based on the etiology of the regurgitant flow, severity of the disease and chronicity.[1]
Based on the Etiology
Pulmonary regurgitation (PR) may be classified into two subtypes based on either intrinsic or extrinsic factors involved in the development of the disease:
- Primary pulmonary regurgitation[2]: The valvular pathology is the cause of PR. Isolated PR is very rare and is most commonly associated with other congenital heart diseases.
- Secondary or functional pulmonary regurgitation[3][4][5]: The pulmonary valve function is normal. Conditions such as pulmonary hypertension and pulmonary artery aneurysm cause dilation of the valve annulus resulting in regurgitation. Secondary PR is more common than primary PR.
Based on the Severity
Pulmonary valve regurgitation may be classified into three categories based on the severity of the regurgitant flow:[6][7]
| Severity | Mild | Moderate | Severe |
|---|---|---|---|
| Valve morphology | Normal | Normal to abnormal | Abnormal |
| Symptom status | Usually asymptomatic | Mild symptoms | Significant symptoms |
| Causes | Physiologic PR | Secondary causes of PR (such as pulmonary artery dilation) |
Post procedure (such as valvulotomy) or anatomic abnormalities of the valve |
Based on the Chronicity
Pulmonic regurgitation (PR) may be classified into two subtypes based on the chronicity of the disease. Chronic diseases are broadly defined as conditions that last 1 year or more.[8]
- Acute PR[9]:
- Severe acute PR may occur due to infective endocarditis and blunt chest trauma with direct injury to heart structures specially among patients with abnormal dilation of pulmonary arteries.
- Acute PR due to endocarditis may be low or high-pressure type. A low-pressure PR may progress to high-pressure PR.
- Chronic PR:
- Chronic low-pressure PR[9]:
- Congenital causes include pulmonic valve abnormalities and idiopathic dilatation of the pulmonary artery (IDPA).
- Acquired cause include post pulmonary valve stenosis repair or TOF repair, tertiary syphilis, chronic endocarditis, rheumatic heart disease, carcinoid heart disease, and Marfan’s syndrome.
- Chronic high-pressure PR: Causes include primary and secondary pulmonary hypertension.
- Chronic low-pressure PR[9]:
Other Classifications
- According to the 2018 ACHD guidelines, moderate or greater pulmonary valve regurgitation lies under moderate complexity according to ACHD (adult congenital heart disease) anatomic and physiological classification.[10]
- Pulmonic regurgitation may lead to right and eventually left heart failure. New York Heart Association's (NYHA) functional classification helps to guage the severity of the heart failure via physical disability of the patient. To read more about the NYHA classification click here.
Staging
The staging described is based on 2014 According to the American Heart Association and American College of Cardiology (AHA/ACC) valvular heart disease 2014 guidelines.
Staging of valvular heart disease (VHD)[11]
Staging is based on the progression of the disease. Although the staging has not been specified for PR, it is a useful tool to access the disease course.
- Stage A (at risk) : Patient has developed risk factors for VHD. Asymptomatic patient. Development of pulmonary hypertension (PAH) as a risk for PR is an example.
- Stage B (progressive): Patient has developed mild-moderate VHD. Asymptomatic patient.
- Stage C (asymptomatic severe): Patient has developed severe VHD. Asymptomatic patient but exercise test can confirm symptom status.
- Stage D (symptomatic severe): Patient has developed severe VHD. Symptomatic patient such as heart failure symptoms.
Staging of severe PR[12]
| Stage | Definition | Pulmonary Valve
Anatomy |
Valve Hemodynamics | Hemodynamic Consequences | Symptoms |
|---|---|---|---|---|---|
| C,D | Severe PR |
|
|
|
|
References
- ↑ Zoghbi, William A.; Adams, David; Bonow, Robert O.; Enriquez-Sarano, Maurice; Foster, Elyse; Grayburn, Paul A.; Hahn, Rebecca T.; Han, Yuchi; Hung, Judy; Lang, Roberto M.; Little, Stephen H.; Shah, Dipan J.; Shernan, Stanton; Thavendiranathan, Paaladinesh; Thomas, James D.; Weissman, Neil J. (2017). "Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation". Journal of the American Society of Echocardiography. 30 (4): 303–371. doi:10.1016/j.echo.2017.01.007. ISSN 0894-7317.
- ↑ Chaturvedi RR, Redington AN (2007). "Pulmonary regurgitation in congenital heart disease". Heart. 93 (7): 880–9. doi:10.1136/hrt.2005.075234. PMC 1994453. PMID 17569817.
- ↑ Di Lullo L, Floccari F, Rivera R, Barbera V, Granata A, Otranto G; et al. (2013). "Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists". Cardiorenal Med. 3 (2): 96–103. doi:10.1159/000350952. PMC 3721135. PMID 23922549.
- ↑ Frigiola, A.; Giardini, A.; Taylor, A.; Tsang, V.; Derrick, G.; Khambadkone, S.; Walker, F.; Cullen, S.; Bonhoeffer, P.; Marek, J. (2012). "Echocardiographic assessment of diastolic biventricular properties in patients operated for severe pulmonary regurgitation and association with exercise capacity". European Heart Journal - Cardiovascular Imaging. 13 (8): 697–702. doi:10.1093/ehjci/jes002. ISSN 2047-2404.
- ↑ Fauci, Anthony (2008). Harrison's principles of internal medicine. New York: McGraw-Hill Medical. ISBN 978-0071466332.
- ↑ Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
- ↑ Lancellotti, P.; Tribouilloy, C.; Hagendorff, A.; Moura, L.; Popescu, B. A.; Agricola, E.; Monin, J. L.; Pierard, L. A.; Badano, L.; Zamorano, J. L.; Sicari, R.; Vahanian, A.; Roelandt, J. R. T. C. (2010). "European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease)". European Journal of Echocardiography. 11 (3): 223–244. doi:10.1093/ejechocard/jeq030. ISSN 1525-2167.
- ↑ "About Chronic Diseases | CDC".
- ↑ 9.0 9.1 DePace, Nicholas L; Nestico, Pasquale F; Iskandrian, Abdulmassih S; Morganroth, Joel (1984). "Acute severe pulmonic valve regurgitation: Pathophysiology, diagnosis, and treatment". American Heart Journal. 108 (3): 567–573. doi:10.1016/0002-8703(84)90425-3. ISSN 0002-8703.
- ↑ Stout, Karen K.; Daniels, Curt J.; Aboulhosn, Jamil A.; Bozkurt, Biykem; Broberg, Craig S.; Colman, Jack M.; Crumb, Stephen R.; Dearani, Joseph A.; Fuller, Stephanie; Gurvitz, Michelle; Khairy, Paul; Landzberg, Michael J.; Saidi, Arwa; Valente, Anne Marie; Van Hare, George F. (2019). "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 139 (14). doi:10.1161/CIR.0000000000000602. ISSN 0009-7322.
- ↑ Nishimura, Rick A.; Otto, Catherine M.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Guyton, Robert A.; O’Gara, Patrick T.; Ruiz, Carlos E.; Skubas, Nikolaos J.; Sorajja, Paul; Sundt, Thoralf M.; Thomas, James D. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Circulation. 129 (23): 2440–2492. doi:10.1161/CIR.0000000000000029. ISSN 0009-7322.
- ↑ 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: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.