Sandbox:Sara.Zand: Difference between revisions

Deep sedation/ intubation (Class IIa)

Recurrent ventricular arrhythmia

Deep sedation/ intubation (Class IIa)

Mechanical circulatory support (Class IIb)

Deep sedation/ intubation (Class IIa)

Deep sedation/ intubation (Class IIa)

Bioprosthetic heart valve

The above algorithm adopted from 2022 ESC Guideline^[1]

AS

V1

_

+

Positive inferior leads

0

1,2

3

1,2

0

V3

Left lateral

Left posterolateral

V1/1 ratio

_

+

Right posterior

Right paraseptal

<1

≥1

_

+

Lead 2, Notched QS

Left posterolateral

Right lateral

Nodo-Hisian

Yes

NO

_

+

Deep coronary sinus

Left paraseptal

Nodo-Hisian

Right atrium

a1

Orthodromic AVRT

Pre-excitation on resting ECG

Yes

NO

Ablation candidate, willing to undergo ablation

Ablation candidate, patient prefers ablation

N0

Yes

NO

Flecainide or propafenone in the absent of structural heart disease (class 2a)

Amiodarone, betablocker, diltiazem, dofetilide, sotalol, verapamil (class 2b)

Catheter ablation (class 1)

Betablocker, diltiazem, verapamil (class1)

Flecainide, propafenone in the absent of structural heart disease (class 2a)

Amiodarone, digoxin, dofetilide, sotalol (class 2b)

If ineffective, consider ablation

Characteristics	Favors SAVR	Favors TAVI	Favors palliation
Age/life expectancy	Younger age/longer life expectancy	Older age/fewer expected remaining years of life	Limited life expectancy
Valve anatomy	BAV Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus	Calcific AS of a trileaflet valve
Prosthetic valve preference	Mechanical or surgical bioprosthetic valve preferred Concern for patient–prosthesis mismatch (annular enlargement might be considered)	Bioprosthetic valve preferred Favorable ratio of life expectancy to valve durability In TAVI valve area is larger than same size SAVR
Concurrent cardiac conditions	Aortic dilation Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF	Severe calcification of the ascending aorta (porcelain aorta)	Irreversible severe LV systolic dysfunction Severe MR attributable to annular calcification
Noncardiac conditions		Severe lung, liver, or renal disease Mobility issues (high procedural risk with sternotomy)	Symptoms likely attributable to noncardiac conditions Severe dementia Moderate to severe involvement of ≥2 other organ systems
Frailty	Not frail or few frailty measures	Frailty likely to improve after TAVI	Severe frailty unlikely to improve after TAVI
Estimated procedural or surgical risk of SAVR or TAVI	SAVR risk low TAVI risk high	TAVI risk low to medium SAVR risk high to prohibitive	Prohibitive SAVR risk (>15%) or post-TAVI life expectancy <1 y
Procedural specific impediments	Valve anatomy, annular size, or low coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI	Previous cardiac surgery with at-risk coronary grafts Previous chest irradiation	Valve anatomy, annular size, or coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI
Goals of Care and patient preferences and values	Less uncertainty about valve durability Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and quality of life Avoid vascular complications Longer hospital stay, pain in recovery period	Uncertainty about valve durability and possible repeat intervention Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and quality of life Shorter hospital stay, less postprocedural pain	Life prolongation not an important goal Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pace maker implantation

The above table adopted from 2020 AHA Guideline^[2]

Recommendations for choice of Mechanical Versus Bioprosthetic AVR

(Class I, Level of Evidence C):

❑ Decision should be made based on patients preference and values after discussion about the risks of anticoagulant therapy or the need for valve re-intervention
❑ Bioprothesis AVR is recommended when anticoagulant theray with VKA is contraindicated, not desired, or can not be managed

(Class IIa, Level of Evidence B):

❑Mechanical aortic prothesis is preferred over bioprosthetic valve for patients < 50 years of age and no contraindication of anticoagulant therapy
❑For patients 50-65 years of age without contraindication of anticoagulant therapy, choosing either mechanical or bioprothesis aortic valve should be individualized based on patient factors
❑ For patients > 65 years of age, bioprosthetic aortic valve is preferred over mechanical aortic valve

(Class IIb, Level of Evidence B):

❑For patients <50 years of age who desire bioprosthetic valve and appropriate anatomy, the Rose procedure including replacement of aortic valve by a pulmonic autograft may be considered

The above table adopted from 2020 AHA Guideline^[2]

Abbreviations: AVR: Aortic valve replacement; VKA: Vitamin K antagonist

Recommendations for choice of SAVR versus TAVI for whom a bioprothetic AVR is approperiate
(Class I, Level of Evidence A):
❑ SAVR is recommended for symptomatic and asymptomatic severe AS, and any indication for AVR, who are < 65 years and life expectancy >20 year ❑Either SAVR or transfemoral TAVI is recommended in symptomatic severe AS who are 65-80 years after evaluation about life expectancy and valve durability ❑TAVI is recommended in symptomatic severe AS who are >80 years or younger patients with life expectancy <10 years and no anatomic contraindication for transfemoral TAVI ❑ TAVI is recommended in symptomatic patients with severe AS in any age and high surgical risk or prohibitive for surgery when predicted survival is > 12 months after TAVI with acceptable quality of life
(Class I, Level of Evidence B):
❑SAVR is recommended in preference to TAVI in asymptomatic severe AS and abnormal exercise stress test, very severe AS, rapid progression, and elevated BNP ❑ In asymptomatic severe AS in age ≤ 80 years of age and LVEF < 50 and no anatomic contraindications for transfemoral TAVI, making decision between TAVI and SAVR is similar to symptomatic patients
(Class I, Level of Evidence C):
❑For symptomatic severe AS when predictive survival is <12 months after TAVI or SAVR and minimal improvement in quality of life is expected, palliative care is recommended
(Class IIb, Level of Evidence C):
❑For critically ill patients with severe AS, percutaneous aortic ballon dilation is a bridge to TAVI or SAVR

The above table adopted from 2020 AHA Guideline^[2]

Abbreviations: SAVR: Surgical aortic valve replacement; TAVI: Transcutaneous aortic valve implantation; AS: Aortic stenosis; LVEF:Left ventricular ejection fraction ;

Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
MVA >1.5 cm²
Left atrial thrombus
More than mild mitral regurgitation
Severe or bi-commissural calcification
Absence of commissural fusion
Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
Concomitant [[cor

b1

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.

c1

Aortic Regurgitation

Moderate Aortic Regurgitation>

Severe Aortic Regurgitation
❑VC>0.6cm
❑ Holodiastolic aortic flow reversal
❑ RVol≥60 ml
❑ RF≥ 50%
❑ ERO≥0.3cm²

Other cardiac surgery

Symptomatic (stage D)

Asymptomatic (stage C)

AVR (Class IIa)

❑ LVEF≤ 55% (stage C2)

❑ Other cardiac surgerysurgery

❑ LVEF> 55%
AND
❑ LVESD > 50mm (LVESD>25mm/m²
)

❑ Progressive decrese in LVEF to <55%-60% or increase in LVEDD to >65mm on at least 3 studies

AVR (Class I)

AVR (Class IIa)

Low surgical risk

AVR (Class IIb)

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter; VC: vena contracta; RVol: regurgitant volume; RF: regurgitant fraction; ERO: effective regurgitant orifice

The above algorithm adopted from 2020 AHA Guideline^[2]

a1

Tricuspid regurgitation

Progressive TR (Stage B)

At time of left sided valve surgery

Severe TR (Stage C,D)

Annular dilation> 4 cm, or perior righ heart failure

Asymptomatic (Stage C)

At time of left sided valve surgery

Right heart failure (Stage D)

TV surgery (2a)

Primary TR with progressive RV dilation or systolic dysfunction

TV surgery (1)

TV surgery (2b)

Primary TR

Prior left sided valve surgery

Secondary TR

TV surgery (2a)

Absent of severe pulmonary hypertension or RV systolic dysfunction

Poor response to medical therapy

TV surgery (2b)

Annular dilation without pulmonary hypertension or left sided disease

TV surgery (2a)

Abbreviations: TR: Tricuspid Regurgitation; TV: Tricuspid valve; RV: Right ventricle

The above algorithm adapted from 2020 AHA Guideline^[2]

A

Recommendations for management of prosthetic valve dysfunction

Mechanical prosthetic thrombosis (Class I, Level of Evidence B):

❑ In patients with obstructive thrombosis who are critically ill patients without serious comorbidities, urgent or emergency valve replacement is recommended

(Class IIa, Level of Evidence B):

❑Fibrinolysis (using recombinant tissue plasminogen activator 10 mg bolus + 90 mg in 90 min with UFH or streptokinase 1500 000 U in 60 min without UFH) should be considered when surgery is very high risk or is not available , or for thrombosis of right-sided prostheses

(Class IIa, Level of Evidence C):

❑Surgery should be considered for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism

Bioprosthetic thrombosis (Class I, Level of Evidence C):

❑ In bioprosthetic valve thrombosis, anticoagulation using a VKA and/or UFH is recommended before considering re-intervention

(Class IIa, Level of Evidence B):

❑ Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion causing elevated gradients, at least until resolution

Hemolysis and paravalvular leak (Class I, Level of Evidence C):

❑ Reoperation is considered when a paravalvular leak is related to endocarditis or leading haemolysis requiring repeated blood transfusions or causes severe heart failure symptoms

(Class IIa, Level of Evidence B):

❑Transcatheter closure is recommended for suitable paravalvular leaks with clinically significant regurgitation and/or haemolysis in high risk patients for surgery

(Class IIa, Level of Evidence C):

❑ Transcatheter or surgical closure of clinically significant paravalvular leaks is considered based on patient risk status, leak morphology, and local expertise

Bioprosthetic failure (Class I, Level of Evidence C):

❑Reoperation is recommended in symptomatic patients with severe regurgitation or a significant increase in transprosthetic gradient (after exclusion of valve thrombosis)

(Class IIa, Level of Evidence B):

❑ Desion of Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team based on anatomic considerations, features of the prosthesis, and high risk patients for surgery or inoperable patients

(Class IIb, Level of Evidence B):

❑ Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in high risk patients for surgery

(Class IIa, Level of Evidence C):

❑Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if reoperation is low risk

The above table adopted from 2021 ESC Guideline^[3]

Abbreviations: UFH: Unfractionated heparin; VKA: Vitamin K antagonist

B

Antithrombotic therapy for valve prostheses

Mechanical heart valve

VKA lifelong (Class I)

Other indications for oral anticoagulation

Add low-dose ASA in low risk patients for bleeding (Class IIb)

NO

Yes

Subtherapeutic INR for major planned invasive procedure

OAC for 3 months (Class IIa)

OAC long-term (Class I)

Bridging anticoagulation with UFH or LMWH (not required for minor surgeries) (Class I)

NO

Yes

SAPT or OAC for 3 months (Class IIa)

OAC long-term (Class I)

NO

Yes

SAPT long-term (Class I)

OAC long-term (Class I)

The above algorithm adopted from 2021 ESC Guideline^[3]

Abbreviations: ASA: acetylsalicylic acid; AF: Atrial fibrillation; CAD: Coronary artery disease; TAVI: Transcatheter aortic valve implantation; DAPT: Dual antiplatelet therapy; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricular; SAVR:Surgical aortic valve replacement; OAC:Oral anticoagulation; SAPT:Single antiplatelet therap; UFH: Unfractionated heparin; VKA:Vitamin K antagonist; TVR:Tricuspid valve replacement or repair; MVR:Mitral valve replacement or repair

C

Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods

Management of antithrombotic therapy in the perioperative period (Class I, Level of Evidence C):

❑It is recommended discontinuation of VKA prior to elective surgery to aim for an INR <1.5
❑Bridging of OAC is recommended in patients with any of the following:

Mechanical prosthetic heart valve
AF with significant mitral stenosis
AF with a CHA2DS2-VASc score ≥ 3 for women or 2 for men
Acute thrombotic event within the previous 4 weeks
High acute thrombotic risk

❑In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to initiate either UFH or LMWH 12-24 h after surgery
❑ Maintaning aspirin therapy , if indicated, is recommended in patients undergoing surgery during the periprocedural period
❑In patients treated with DAPT after recent PCI (within 1 month) requiring heart valve surgery in the absence of an indication for OAC, starting the P2Y12 inhibitor postoperatively is recommended

(Class I, Level of Evidence B):

❑For bridging, therapeutic doses of either UFH or subcutaneous LMWH are recommended

(Class I, Level of Evidence C):

❑ Re-initiation of the VKA on the first postoperative day is recommended in patients with mechanical valve

(Class IIb, Level of Evidence C):

❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism

Concomitant antiplatelet therapy (Class I, Level of Evidence B):

❑If the risk of stent thrombosis is low, in patients undergone PCI or after ACS requiring long-term OAC, early cessation (≤1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended
❑ In patients treated with an OAC, discontinuation of antiplatelet treatment is recommended after 12 months

(Class IIa, Level of Evidence C):

❑If the risk of stent thrombosis is high, in patients undergone PCI or after ACS requiring both OAC and antiplatelet therapy, triple therapy with aspirin, clopidogrel and OAC for longer than 1 week should be considered with the total duration (≤1 month)

(Class IIa, Level of Evidence B):

❑In patients with mechanical heart valve treated with a VKA and low risk for stent thrombosis and HAS-BLED ≥ 3 , clopidogrel alone should be considered for up to 12 months
❑In patients requiring aspirin and/or clopidogrel in addition to VKA, target INR should be considered in the lower part of the recommended target

Surgical valve replacement (Class I, Level of Evidence B):

❑For all patients with an mechanical heart valve prosthesis, OAC using a VKA is recommended lifelong
❑ For patients with biological heart valve, OAC is recommended if they have other indications for anticoagulation

(Class IIa, Level of Evidence B):

❑ In patients with biological heart valve and AF, NOACs should be considered over VKA after 3 months following surgical implantation
❑ In patients with an aortic biological heart valve, low-dose aspirin (75-100 mg/day) or OAC using a VKA should be considered for the first 3 months after surgical implantation
❑ In patients with a mitral or tricuspid biological heart valve, OAC using a VKA should be considered for the first 3 months after surgical implantation

(Class IIb, Level of Evidence C):

❑ In patients with mechanical heart valve and evidence of atherosclerotic disease and low risk of bleeding, The addition of low-dose aspirin (75-100 mg/ day) to VKA may be considered in selected patients
❑NOACs may be considered over VKA within 3 months following surgical implantation of a biological heart valve in mitral position in patients with AF

(Class IIa, Level of Evidence C):

❑ Low-dose aspirin (75-100 mg/day) in addition to VKA should be considered after thromboembolism despite an adequate INR

(Class III, Level of Evidence B):

❑NOACs are not recommended in patients with a mechanical valve prosthesis

Surgical valve repair (Class IIa, Level of Evidence C):

❑OAC with VKA should be considered during the first 3 months after mitral and tricuspid repair
❑SAPT with low-dose ASA (75-100 mg/day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications to

Transcatheter aortic valve replacement (Class I, Level of Evidence B):

❑OAC is recommended lifelong for TAVI patients who have other indications for OAC

(Class I, Level of Evidence A):

❑Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC

(Class III, Level of Evidence B):

❑ Routine use OAC is not recommended after TAVI in patients with no baseline indication for OAC

The above table adopted from 2021 ESC Guideline^[3]

Abbreviations: ACS: Acute coronary syndrome; AF: Atrial fibrillation; NOAC: Non-vitamin K antagonist oral anticoagulant; TAVI: Transcatheter aortic valve implantation; DAPT: Dual antiplatelet therapy; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricular; PCI:Percutaneous coronary intervention; OAC:Oral anticoagulation; SAPT:Single antiplatelet therap; UFH: Unfractionated heparin; VKA:Vitamin K antagonist

D

Recommendations for prosthetiv valve disease
Mechanical protheses (Class I, Level of Evidence C):
❑A mechanical prosthesis is recommended according to the desire of the informed patient and NO contraindications to long term anticoagulation ❑A mechanical prosthesis is recommended in patients at risk of structural valve deterioration
(Class IIa, Level of Evidence C):
❑A mechanical prosthesis should be considered in patients already on anticoagulation because of a mechanical prosthesis in another valve position ❑A mechanical prosthesis should be considered in patients with a reasonable life expectancy and high risk for redo valve surgery or TAVI
(Class IIa, Level of Evidence B):
❑A mechanical prosthesis should be considered in patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position
(Class IIb, Level of Evidence C):
❑A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism
Biological prothesis (Class I, Level of Evidence C):
❑A bioprosthesis is recommended according to the desire of the informed patient ❑A bioprosthesis is recommended when anticoagulant theray is contraindicated because of high bleeding risk (previous major bleed, comorbidities, unwillingness, adherence problems, lifestyle, occupation and low life expectancy ❑A bioprosthesis is recommended in case of reoperation for mechanical valve thrombosis despite good anticoagulation
(Class IIa, Level of Evidence C):
❑A bioprosthesis should be considered in patients for whom there is a low likelihood and/or a low operative risk of future redo valve surgery ❑A bioprosthesis should be considered in young women in the age of pregnancy ❑A bioprosthesis should be considered in patients aged >65 years for a prosthesis in the aortic position or aged >70 years in a mitral position
(Class IIb, Level of Evidence B):
❑A bioprosthesis may be considered in patients already on long-term NOACs for whom are high risk for thromboembolism

The above table adopted from 2021 ESC Guideline^[3]

Abbreviations: TAVI: Transcatheter aortic valve implantation; AF: Atrial fibrillation; NOAC: Non-vitamin K antagonist oral anticoagulant;

G

Recommendations for intervention in tricuspid valve disease
Tricuspid stenosis (Class I, Level of Evidence C):
❑ Surgery is recommended in symptomatic patients with severe tricuspid stenosis ❑ Surgery is recommended in patients with severe tricuspid stenosis undergoing left-sided valve intervention
Primary Tricuspid Regurgitation (Class I, Level of Evidence C):
❑Surgery is recommended in patients with severe primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery is recommended in symptomatic patients with isolated severe primary tricuspid regurgitation without severe RV dysfunction
Primary Tricuspid Regurgitation (Class IIa, Level of Evidence C):
❑Surgery should be considered in patients with moderate primary tricuspid regurgitation undergoing left-sided valve surgery ❑Surgery should be considered in asymptomatic or mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery
Secondary Tricuspid Regurgitation (Class I, Level of Evidence B):
❑Surgery is recommended in patients with severe secondary tricuspid regurgitation undergoing left-sided valve surgery
Secondary Tricuspid Regurgitation (Class IIa, Level of Evidence B):
❑Surgery should be considered in patients with mild or moderate secondary tricuspid regurgitation with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery ❑Surgery should be considered in patients with severe secondary tricuspid regurgitation (with or without previous left-sided surgery) who are symptomatic or have RV dilatation, in the absence of severe RV or LV dysfunction and severe pulmonary vascular disease/ pulmonary hypertension
Secondary Tricuspid Regurgitation (Class IIb, Level of Evidence C):
❑Transcatheter treatment of symptomatic secondary severe tricuspid regurgitation may be considered in inoperable patients

The above table adopted from 2021 ESC Guideline^[3]

=F

Management of clinically significant rheumatic mitral stenosis (MVA ≤ 1.5 cm2)

NO

Yes

High risk of embolism or hemodynamic decompensation

Contraindication to PMC

Yes

NO

Yes

PMC if favourable characteristics for PMC or contraindication for surgery

Surgery if unfavourable charactristics for PMC

Exercise test

Contraindication or high risk for surgery

Yes

NO

Yes

PMC

Favourable anatomical characteristics

Follow-up

Contraindication to or unfavourable characteristics for PMC

NO

Yes

NO

Yes

PMC

Abbreviations: PMC: Percutaneous mitral commissurotomy; MVA:Mitral valve area

The above algorithm adopted from 2021 ESC Guideline^[3]

K

Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)
(Class I, Level of Evidence B):
❑ PMC is recommended in symptomatic patients with favourable characteristics for PMC
(Class I, Level of Evidence C):
❑PMC is recommended in any symptomatic patients who are high risk for surgery ❑Mitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility
(Class IIa, Level of Evidence C):
❑PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy and favourable clinical characteristics for PMC ❑PMC should be considered in asymptomatic patients with favourable clinical and anatomical characteristicsc for PMC and: High thromboembolic risk (history of systemic embolism, spontaneous contrast in the left artium, new-onset or paroxysmal AF), and/or High risk of hemodynamic decompensation (systolic pulmonary pressure >50 mmHg at rest, need for major non-cardiac surgery, desire for pregnancy)

The above table adopted from 2021 ESC Guideline^[3]

Abbreviations: PMC: Percutaneous mitral commissurotomy; AF: Atrial fibrillation; LA: Left atrium; MVA:Mitral valve area ;

Contraindications for percutaneous mitral commissurotomy in rheumatic mitral stenosis
MVA >1.5 cm²
Left atrial thrombus
More than mild mitral regurgitation
Severe or bi-commissural calcification
Absence of commissural fusion
Severe concomitant aortic valve disease, or severe combined tricuspid stenosis and tricuspid regurgitation requiring surgery
Concomitant coronary artery disease requiring bypass surgery

P

Management of patients with chronic severe secondary mitral regurgitation

Symptomatic despite medical therapy

*Optimazing medical therapy

CRT implantation if indicated

Severe comorbidities or life expectancy < 1 year

Yes

NO

Palliative care

Presence of CAD or other cardiac disease

Yes

NO

Appropriate for surgery

Persisting severe symptomatic secondary MR

Valve surgery if fulfilling criteria

Yes

NO

CABG, MV surgery

PCI, TAVI

Persisting severe symptomatic secondary MR

Yes

Appropriate for valve surgery

NO

Close follow-up

Yes

MV surgery

NO

End-stage LV, RV failure

Yes

Heart transplantation, left ventricular assist devices palliative care

NO

Fulfilling criteria suggesting an increased chance of responding to TEER

Yes=TEER

NO

Heart transplantation, left ventricular assist devices palliative care, TEER in selected cases or other transcatheter valve therapy if applicable for symptoms improvement

The above algorithm adopted from 2021 ESC Guideline^[3]

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; MV:Mitral valve ; PCI:Percutaneous coronary intervention; LVAD: Left ventricular assist devices; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation; CAD: Coronary artery disease

T

Recommendations for intervention in chronic severe secondary mitral regurgitation
(Class I, Level of Evidence B):
❑ Valve surgery/intervention is recommended in symptomatic severe secondary MR despite GDMT or CRT ❑Valve surgery is recommended in patients undergoing CABG or other cardiac surgery
(Class IIa, Level of Evidence B):
❑TEER should be considered in selected symptomatic patients, not suitable for surgery and high likelihood of responding to TEER
(Class IIa, Level of Evidence C):
❑ In symptomatic inoperable patients, PCI (and/orTAVI) possibly followed by TEER (in case of persisting severe secondary MR) should be considered
(Class IIb, Level of Evidence C) :
❑ Valve surgery may be considered in symptomatic patients who are appropriate for surgery ❑In high-risk symptomatic patients not eligible for surgery and low likelihood of responding to TEER, making decision about TEER procedure or other transcatheter valve therapy and evaluation for ventricular assist device or heart transplant should be considered

The above table adopted from 2021 ESC Guideline^[3]

Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; ERO:Effective regurgitation orifice area ; PCI:Percutaneous coronary intervention; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation

U

Management of patients with severe chronic primary mitral regurgitation

Yes

NO

Determining the risk of surgery

LVEF ≤ 60% or LVESD ≥ 40 mm

High risk of futility

Palliative therapy

High risk for surgery or inoperable

Yes

NO

Yes

NO

Surgical mitral valve repair

New onset AF or SPAP>50 mmHg

TEER if anatomically suitable, optimal heart failure therapy

Surgery (repair whenever possible)

Yes, surgery

NO

High likelihood of durable repair, low surgical risk, and LA dilatation

NO

Yes

Follow-up

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

The above algorithm adopted from 2021 ESC Guideline^[3]

I

Recommendations for intervention in primary mitral regurgitation

(Class I, Level of Evidence B):
❑ Mitral valve repair is considered when the results of surgical technique are expected to be durable ❑ Surgery is recommended in low risk symptomatic patients ❑ Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD ≥ 40 mm and/or LVEF ≤ 60%)
(Class IIa, Level of Evidence B):
❑ Surgery is recommended in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg) ❑Surgical mitral valve repair is recommended in low-risk asymptomatic patients with LVEF > 60%, LVESD <40 mmd and significant LA dilatation (volume index ≥60 mL/m2 or diameter ≥55 mm)
(Class IIb, Level of Evidence B) :
❑TEER may be considered in symptomatic patients who are inoperable due to high surgical risk, with echocardiographic criteria of eligibility

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;

The above table adopted from 2021 ESC Guideline^[3]

O

Recommendations for intervention in aortic stenosis

Symptomatic aortic stenosis:

(Class I, Level of Evidence B):

❑ Intervention is considered in symptomatic patients with severe, high-gradient aortic stenosis mean gradient ≥ 40 mmHg, peak velocity ≥ 4.0 m/s, and valve area ≤ 1.0 cm2 (or ≤ 0.6 cm2/m2)
❑ntervention is considered in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) aortic stenosis with reduced ejection fraction (<50%), and evidence of flow (contractile) reserve

(Class IIa, Level of Evidence C):

❑ Intervention is recommended in symptomatic severe AS with low-flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection fraction
❑ Intervention is recommended in symptomatic patients with low-flow, low-gradient severe aortic stenosis and reduced ejection fraction without flow (contractile) reserve, severe aortic stenosis proven by CCT calcium score

(Class III, Level of Evidence C) :

❑ Intervention is not recommended in patients with severe comorbidities when the intervention is unlikely to improve quality of life or prolong survival >1 year

Asymptomatic severe aortic stenosis :

(Class I, Level of Evidence B):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) without another cause

(Class I, Level of Evidence C):

❑ Intervention is recommended in asymptomatic patients with severe aortic stenosis, symptomtomatic on exercise testing

(Class IIa, Level of Evidence B):

❑ Intervention should be considered in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF <55%) without another cause

(Class IIa, Level of Evidence C):

❑ Interventin is recommended in asymptomatic patients with severe aortic stenosis and a sustained fall inblood pressure (>20 mmHg) during exercise testing

(Class IIa, Level of Evidence B):

❑Intervention is considered in asymptomatic patients with LVEF >55% and a normal exercise test if the procedural risk is low and in the presence of one of the following:

Very severe aortic stenosis (mean gradient ≥60 mmHg or Vmax > 5 m/s
Severe valve calcification ( assessed by CCT) and Vmax progression ≥0.3 m/s/year
Elevated BNP levels (>3× age- and sex-corrected normal range) confirmed by repeated measurements and without other causes

Type of intervention:

(Class I, Level of Evidence C):

❑Aortic valve interventions should be performed in an experienced center

(Class I, Level of Evidence B):

❑SAVR is recommended in younger patients who are low risk for surgery (<75 yearse and STS PROM/EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI
❑SAVR or TAVI are recommended for patients based on clinical, anatomical, and procedural characteristics

(Class I, Level of Evidence A):

❑TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS PROM/EuroSCORE IIf>8%) or unsuitable for surgery

(Class IIb, Level of Evidence C):

❑ Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI. ❑Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in hemodynamically unstable patients and (if feasible) in those with severe aortic stenosis who require urgent high risk non-cardiac surgery

Abbreviations: BNP: B-type natriuretic peptide; CABG: Coronary artery bypass grafting; LV: Left ventricle; LVEF:Left ventricular ejection fraction ; CCT:Cardiac computed tomography; SAVR: Surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons - predicted risk of mortality; SVi: Stroke volume index; TAVI:Transcatheter aortic valve implantation ; Vmax:Peak transvalvular velocity

The above table adopted from 2021 ESC Guideline^[3]

R

Clinical characteristics	Favours TAVI	Favours SAVR
Lower surgical risk	_	+
Higher surgical risk	+	_
Younger age	_	+
Older age	+	_
Previous cardiac surgery (CABG)	+	_
Severe frailty	+	_
Endocarditis	_	+
Anatomical and procedural factors
TAVI feasible via transfemoral approach	+	_
Inaccessable Transfemoral approach or SAVR feasible	_	+
Sequelae of chest radiation	+	_
Porcelain aorta	+	_
High likelihood of severe patient-prosthesis mismatch (AVA <0.65 cm2/m2 BSA)	+	_
Severe chest deformity or scoliosis	+	_
Unsuitable aortic annular dimensions for TAVI device	_	+
Bisuspid aortic valve	_	+
Unfavourable valve morphology for TAVI (high risk of coronary obstruction due to low coronary ostia or heavy leaflet/LVOT calcification	_	+
Thrombus in aorta or left ventricle	_	+
Concomitant cardiac conditions requiring interventio
Significant multi-vessel CAD requiring surgical revascularization	_	+
Severe primary mitral valve disease	_	+
Severe tricuspid valve disease	_	+
Significant dilatation/aneurysm of the aortic root and/or ascending aorta	_	+
Septal hypertrophy requiring myomectomy	_	+

Abbreviations: AV: Aortic valve; AVA: Aortic valve area; LVOT: Left ventricular outflow tract ; SAVR: Surgical aortic valve replacement; TAVI: Transcatheter aortic valve implantation; BSA: Body surface area; CAD: Coronary artery disease

The above table adopted from 2021 ESC Guideline^[3]

Y

Valvular AS

Assessment of velocity, gradient

Low-gradient AS

Vmax < 4 m/s
ΔPm < 40 mmHg

High-gradient AS

Vmax ≥ 4 m/s,

ΔPm ≥ 40 mmHg

AVA ≤ 1.0 cm2

High flow status

Yes

Determination of flow status

NO

Moderate AS

Yes

Assessment of normal flow condition

NO

Severe AS

Normal flow

SVi > 35 mL/m2

Low flow

SVi ≤ 35 mL/m2

Severe AS unlikely

LVEF ≥ 50%

NO

DSE flow reservec

Yes

CCT to assess AV calcification

NO, CCT to assess AV calcification

Yes, AVA ≤ 1.0 cm2

Yes

Severe AS

NO

Pseudo-severe AS

Abbreviations: AS: Aortic stenosis; AV: Aortic valve; AVA: Aortic valve area; LVEF: Left ventricular ejection fraction ; CT: Computed tomography; △Pm: Mean pressure gradient; DSE: Dobutamine stress echocardiography; LV: Left ventricular; SVi: Stroke volume index; Vmax: Peak transvalvular velocity

The above table adopted from 2021 ESC Guideline^[3]

High flow is reversible in conditions such as anemia, hyperthyroidism orarterio-venous fistula and may also be present in patients with hypertrophic obstructive cardiomyopathy.
The definition of Normal flow by pulsed Doppler echocardiography is :
Cardiac index 4.1 L/min/m2 in men and women

SVi 54 mL/m2 in men, 51 mL/m2 in women
DSE flow reserve is defined as > 20% increase in stroke volume in response to low-dose dobutamine.
Pseudo-severe aortic stenosis is defined as AVA >1.0 cm2 with increased flow.
CT measurement of aortic valve calcification (Agatston units) for definition of high likely severe AS:
men >3000, women>1600

Likely: men >2000, women >1200

Unlikely: men <1600, women <800

E

Management of aortic regurgitation

Significant enlargement of ascending aorta

Severe aortic regurgitation