Tricuspid regurgitation medical therapy: Difference between revisions

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Latest revision as of 15:06, 8 December 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Vamsikrishna Gunnam M.B.B.S [2] Rim Halaby, M.D. [3] Fatimo Biobaku M.B.B.S [4]

Overview

The main therapy to tricuspid regurgitation is the treatment of the underlying cause. The aim of medical therapy among patients with tricuspid regurgitation is to treat right heart failure, left heart failure, and/or pulmonary hypertension in case they are present. Medical therapy with diuretics is given to reduce volume overload. Treatment with medications such as vasodilators to relieve pulmonary hypertension may also be of benefit.

Medical Therapy

The majority of cases of tricuspid regurgitation are require and can be approached by the medical therapy alone.
In patients with tricuspid regurgitation the physician should instruct the patient to reduce the overall salt intake.
In patients with tricuspid regurgitation intervention with medical therapy can be done for the following:^[1]
- Atrial fibrillation
- Chronic kidney disease

Right Heart Failure

Patients with severe tricuspid regurgitation and symptoms of right heart failure should receive diuretics in order to reduce the following:^[2]
- Volume overload
- Peripheral edema
- Ascites
Loop diuretics are commonly used to relive some of the symptoms from the volume overload.
Aldosterone antagonists can be beneficial among patients with hyperaldosteronism secondary to hepatic congestion.
Diuretics should be administered intravenously whenever the patient has intestinal edema as oral treatment with diuretics is inefficacious.^[3]

Left Heart Failure

If left heart failure is present, the therapeutic strategy should be targeted towards the treatment of the underlying pathophysiological mechanism.
Pharmacologic medical therapy is recommended among patients with left ventricular systolic dysfunction with beta-blockers, renin-angiotensin-aldosterone system inhibitors and digitalis.

Pulmonary Hypertension

The selective use of pulmonary vasodilators in patients with pulmonary artery hypertension may improve the valvular regurgitation.^[4]^[5]

Pregnancy

In patients with tricuspid regurgitation who are pregnant can be managed by evaluated the following:^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]
- Timing
- Preconception evaluation
  - Which includes a detailed history, information on any prior valve interventions, a complete physical exam and a 12 lead electrocardiogram should be considered
- Echocardiographic assessment
  - Helps in determine the type and severity of valvular lesions
  - Safer and less invasive
  - Maternal left ventricular diastolic function and systolic function can be evaluated
  - Any cardiac hemodynamic changes or remodeling can be evaluated in pregnancy
- Exercise testing
  - Exercise testing which includes heart rate response should be considered to access the risk and can objectively estimate functional capacity
- Biomarkers can predict the cardiovascular complications in pregnancy and the following can be used to elevate:
  - N-terminal pro-B-type natriuretic peptide
  - B-type natriuretic peptide
- Medications
  - Review of the patients current medications and should consider lowering or to stop some of medications that might be teratogenic.

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^[15]

Recommendations for Medical Therapy for TR

Class IIa
1. In patients with signs and symptoms of right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful (Level of Evidence: C-EO) 2. In patients with signs and symptoms of right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF (eg, pulmonary vasodilators to reduce elevated pulmonary artery pressures, GDMT for HF with reduced LVEF, or rhythm control of AF) can be useful(Level of Evidence: C-EO)

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)^[16]^[17]^[18]

Class IIa
"1. Diuretics can be useful for patients with severe TR and signs of right-sided HF (stage D). (Level of Evidence: C)"

Class IIb
"1. Medical therapies to reduce elevated pulmonary artery pressures and/or pulmonary vascular resistance might be considered in patients with severe functional TR (stages C and D). (Level of Evidence: C)"

References

↑ Ingraham BS, Pislaru SV, Nkomo VT, Nishimura RA, Stulak JM, Dearani JA; et al. (2019). "Characteristics and treatment strategies for severe tricuspid regurgitation". Heart. 105 (16): 1244–1250. doi:10.1136/heartjnl-2019-314741. PMID 31092546.
↑ 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". Journal of the American College of Cardiology. 63 (22): e57–e185. doi:10.1016/j.jacc.2014.02.536. ISSN 0735-1097.
↑ Bruce CJ, Connolly HM (2009). "Right-sided valve disease deserves a little more respect". Circulation. 119 (20): 2726–34. doi:10.1161/CIRCULATIONAHA.108.776021. PMID 19470901.
↑ Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check |pmid= value (help).
↑ Antoniou T, Koletsis EN, Prokakis C, Rellia P, Thanopoulos A, Theodoraki K; et al. (2013). "Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery". J Cardiothorac Vasc Anesth. 27 (3): 459–66. doi:10.1053/j.jvca.2012.07.020. PMID 23063102.
↑ Kovacs, Adrienne H.; Harrison, Jeanine L.; Colman, Jack M.; Sermer, Mathew; Siu, Samuel C.; Silversides, Candice K. (2008). "Pregnancy and Contraception in Congenital Heart Disease: What Women Are Not Told". Journal of the American College of Cardiology. 52 (7): 577–578. doi:10.1016/j.jacc.2008.05.013. ISSN 0735-1097.
↑ Bamfo JE, Kametas NA, Nicolaides KH, Chambers JB (2007). "Maternal left ventricular diastolic and systolic long-axis function during normal pregnancy". Eur J Echocardiogr. 8 (5): 360–8. doi:10.1016/j.euje.2006.12.004. PMID 17321800.
↑ Jimenez-Juan L, Krieger EV, Valente AM, Geva T, Wintersperger BJ, Moshonov H; et al. (2014). "Cardiovascular magnetic resonance imaging predictors of pregnancy outcomes in women with coarctation of the aorta". Eur Heart J Cardiovasc Imaging. 15 (3): 299–306. doi:10.1093/ehjci/jet161. PMID 24037808.
↑ Waksmonski CA (2014). "Cardiac imaging and functional assessment in pregnancy". Semin Perinatol. 38 (5): 240–4. doi:10.1053/j.semperi.2014.04.012. PMID 25037513.
↑ Lui GK, Silversides CK, Khairy P, Fernandes SM, Valente AM, Nickolaus MJ; et al. (2011). "Heart rate response during exercise and pregnancy outcome in women with congenital heart disease". Circulation. 123 (3): 242–8. doi:10.1161/CIRCULATIONAHA.110.953380. PMID 21220738.
↑ Kampman MA, Balci A, van Veldhuisen DJ, van Dijk AP, Roos-Hesselink JW, Sollie-Szarynska KM; et al. (2014). "N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease". Eur Heart J. 35 (11): 708–15. doi:10.1093/eurheartj/eht526. PMID 24334717.
↑ Kampman MA, Balci A, van Veldhuisen DJ, van Dijk AP, Roos-Hesselink JW, Sollie-Szarynska KM; et al. (2014). "N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease". Eur Heart J. 35 (11): 708–15. doi:10.1093/eurheartj/eht526. PMID 24334717.
↑ Tanous D, Siu SC, Mason J, Greutmann M, Wald RM, Parker JD; et al. (2010). "B-type natriuretic peptide in pregnant women with heart disease". J Am Coll Cardiol. 56 (15): 1247–53. doi:10.1016/j.jacc.2010.02.076. PMID 20883932.
↑ Ducas RA, Elliott JE, Melnyk SF, Premecz S, daSilva M, Cleverley K; et al. (2014). "Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study". J Cardiovasc Magn Reson. 16: 1. doi:10.1186/1532-429X-16-1. PMC 3882291. PMID 24387349.
↑ 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).
↑ Vahanian, Alec; Alfieri, Ottavio; Andreotti, Felicita; Antunes, Manuel J.; Barón-Esquivias, Gonzalo; Baumgartner, Helmut; Borger, Michael Andrew; Carrel, Thierry P.; De Bonis, Michele; Evangelista, Arturo; Falk, Volkmar; Iung, Bernard; Lancellotti, Patrizio; Pierard, Luc; Price, Susanna; Schäfers, Hans-Joachim; Schuler, Gerhard; Stepinska, Janina; Swedberg, Karl; Takkenberg, Johanna; Von Oppell, Ulrich Otto; Windecker, Stephan; Zamorano, Jose Luis; Zembala, Marian; Bax, Jeroen J.; Baumgartner, Helmut; Ceconi, Claudio; Dean, Veronica; Deaton, Christi; Fagard, Robert; Funck-Brentano, Christian; Hasdai, David; Hoes, Arno; Kirchhof, Paulus; Knuuti, Juhani; Kolh, Philippe; McDonagh, Theresa; Moulin, Cyril; Popescu, Bogdan A.; Reiner, Željko; Sechtem, Udo; Sirnes, Per Anton; Tendera, Michal; Torbicki, Adam; Vahanian, Alec; Windecker, Stephan; Popescu, Bogdan A.; Von Segesser, Ludwig; Badano, Luigi P.; Bunc, Matjaž; Claeys, Marc J.; Drinkovic, Niksa; Filippatos, Gerasimos; Habib, Gilbert; Kappetein, A. Pieter; Kassab, Roland; Lip, Gregory Y.H.; Moat, Neil; Nickenig, Georg; Otto, Catherine M.; Pepper, John; Piazza, Nicolo; Pieper, Petronella G.; Rosenhek, Raphael; Shuka, Naltin; Schwammenthal, Ehud; Schwitter, Juerg; Mas, Pilar Tornos; Trindade, Pedro T.; Walther, Thomas (2012). "Guidelines on the management of valvular heart disease (version 2012)". European Heart Journal. 33 (19): 2451–2496. doi:10.1093/eurheartj/ehs109. ISSN 1522-9645.
↑ 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.
↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM, Thompson A (June 2017). "2017 AHA/ACC Focused Update of the 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 Clinical Practice Guidelines". Circulation. 135 (25): e1159–e1195. doi:10.1161/CIR.0000000000000503. PMID 28298458.

Template:WH Template:WS

[pmid31092546-1] Ingraham BS, Pislaru SV, Nkomo VT, Nishimura RA, Stulak JM, Dearani JA; et al. (2019). "Characteristics and treatment strategies for severe tricuspid regurgitation". Heart. 105 (16): 1244–1250. doi:10.1136/heartjnl-2019-314741. PMID 31092546.

[NishimuraOtto2014-2] 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". Journal of the American College of Cardiology. 63 (22): e57–e185. doi:10.1016/j.jacc.2014.02.536. ISSN 0735-1097.

[pmid19470901-3] Bruce CJ, Connolly HM (2009). "Right-sided valve disease deserves a little more respect". Circulation. 119 (20): 2726–34. doi:10.1161/CIRCULATIONAHA.108.776021. PMID 19470901.

[pmidPMID:_27048553-4] Rodés-Cabau J, Taramasso M, O'Gara PT (2016). "Diagnosis and treatment of tricuspid valve disease: current and future perspectives". Lancet. 388 (10058): 2431–2442. doi:10.1016/S0140-6736(16)00740-6. PMID 27048553 PMID: 27048553 Check |pmid= value (help).

[pmid23063102-5] Antoniou T, Koletsis EN, Prokakis C, Rellia P, Thanopoulos A, Theodoraki K; et al. (2013). "Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery". J Cardiothorac Vasc Anesth. 27 (3): 459–66. doi:10.1053/j.jvca.2012.07.020. PMID 23063102.

[KovacsHarrison2008-6] Kovacs, Adrienne H.; Harrison, Jeanine L.; Colman, Jack M.; Sermer, Mathew; Siu, Samuel C.; Silversides, Candice K. (2008). "Pregnancy and Contraception in Congenital Heart Disease: What Women Are Not Told". Journal of the American College of Cardiology. 52 (7): 577–578. doi:10.1016/j.jacc.2008.05.013. ISSN 0735-1097.

[pmid17321800-7] Bamfo JE, Kametas NA, Nicolaides KH, Chambers JB (2007). "Maternal left ventricular diastolic and systolic long-axis function during normal pregnancy". Eur J Echocardiogr. 8 (5): 360–8. doi:10.1016/j.euje.2006.12.004. PMID 17321800.

[pmid24037808-8] Jimenez-Juan L, Krieger EV, Valente AM, Geva T, Wintersperger BJ, Moshonov H; et al. (2014). "Cardiovascular magnetic resonance imaging predictors of pregnancy outcomes in women with coarctation of the aorta". Eur Heart J Cardiovasc Imaging. 15 (3): 299–306. doi:10.1093/ehjci/jet161. PMID 24037808.

[pmid25037513-9] Waksmonski CA (2014). "Cardiac imaging and functional assessment in pregnancy". Semin Perinatol. 38 (5): 240–4. doi:10.1053/j.semperi.2014.04.012. PMID 25037513.

[pmid21220738-10] Lui GK, Silversides CK, Khairy P, Fernandes SM, Valente AM, Nickolaus MJ; et al. (2011). "Heart rate response during exercise and pregnancy outcome in women with congenital heart disease". Circulation. 123 (3): 242–8. doi:10.1161/CIRCULATIONAHA.110.953380. PMID 21220738.

[pmid24334717-11] Kampman MA, Balci A, van Veldhuisen DJ, van Dijk AP, Roos-Hesselink JW, Sollie-Szarynska KM; et al. (2014). "N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease". Eur Heart J. 35 (11): 708–15. doi:10.1093/eurheartj/eht526. PMID 24334717.

[pmid243347172-12] Kampman MA, Balci A, van Veldhuisen DJ, van Dijk AP, Roos-Hesselink JW, Sollie-Szarynska KM; et al. (2014). "N-terminal pro-B-type natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease". Eur Heart J. 35 (11): 708–15. doi:10.1093/eurheartj/eht526. PMID 24334717.

[pmid20883932-13] Tanous D, Siu SC, Mason J, Greutmann M, Wald RM, Parker JD; et al. (2010). "B-type natriuretic peptide in pregnant women with heart disease". J Am Coll Cardiol. 56 (15): 1247–53. doi:10.1016/j.jacc.2010.02.076. PMID 20883932.

[pmid24387349-14] Ducas RA, Elliott JE, Melnyk SF, Premecz S, daSilva M, Cleverley K; et al. (2014). "Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study". J Cardiovasc Magn Reson. 16: 1. doi:10.1186/1532-429X-16-1. PMC 3882291. PMID 24387349.

[pmid33332150-15] 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).

[VahanianAlfieri2012-16] Vahanian, Alec; Alfieri, Ottavio; Andreotti, Felicita; Antunes, Manuel J.; Barón-Esquivias, Gonzalo; Baumgartner, Helmut; Borger, Michael Andrew; Carrel, Thierry P.; De Bonis, Michele; Evangelista, Arturo; Falk, Volkmar; Iung, Bernard; Lancellotti, Patrizio; Pierard, Luc; Price, Susanna; Schäfers, Hans-Joachim; Schuler, Gerhard; Stepinska, Janina; Swedberg, Karl; Takkenberg, Johanna; Von Oppell, Ulrich Otto; Windecker, Stephan; Zamorano, Jose Luis; Zembala, Marian; Bax, Jeroen J.; Baumgartner, Helmut; Ceconi, Claudio; Dean, Veronica; Deaton, Christi; Fagard, Robert; Funck-Brentano, Christian; Hasdai, David; Hoes, Arno; Kirchhof, Paulus; Knuuti, Juhani; Kolh, Philippe; McDonagh, Theresa; Moulin, Cyril; Popescu, Bogdan A.; Reiner, Željko; Sechtem, Udo; Sirnes, Per Anton; Tendera, Michal; Torbicki, Adam; Vahanian, Alec; Windecker, Stephan; Popescu, Bogdan A.; Von Segesser, Ludwig; Badano, Luigi P.; Bunc, Matjaž; Claeys, Marc J.; Drinkovic, Niksa; Filippatos, Gerasimos; Habib, Gilbert; Kappetein, A. Pieter; Kassab, Roland; Lip, Gregory Y.H.; Moat, Neil; Nickenig, Georg; Otto, Catherine M.; Pepper, John; Piazza, Nicolo; Pieper, Petronella G.; Rosenhek, Raphael; Shuka, Naltin; Schwammenthal, Ehud; Schwitter, Juerg; Mas, Pilar Tornos; Trindade, Pedro T.; Walther, Thomas (2012). "Guidelines on the management of valvular heart disease (version 2012)". European Heart Journal. 33 (19): 2451–2496. doi:10.1093/eurheartj/ehs109. ISSN 1522-9645.

[pmid24589852-17] 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.

[pmid28298458-18] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM, Thompson A (June 2017). "2017 AHA/ACC Focused Update of the 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 Clinical Practice Guidelines". Circulation. 135 (25): e1159–e1195. doi:10.1161/CIR.0000000000000503. PMID 28298458.

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@@ Line 52: / Line 52: @@
 ***Review of the patients current medications and should consider lowering or to stop some of [[Medication|medications]] that might be [[teratogenic]].
-<br />
+== 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> ==
+=== Recommendations for Medical Therapy for TR ===
+{| 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 signs and symptoms of right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C-EO)'']]
+.   In patients with signs and symptoms of right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF (eg, pulmonary vasodilators to reduce elevated pulmonary artery pressures, GDMT for HF with reduced LVEF, or rhythm control of AF) can be useful([[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 (DO NOT EDIT)<ref name="VahanianAlfieri2012">{{cite journal|last1=Vahanian|first1=Alec|last2=Alfieri|first2=Ottavio|last3=Andreotti|first3=Felicita|last4=Antunes|first4=Manuel J.|last5=Barón-Esquivias|first5=Gonzalo|last6=Baumgartner|first6=Helmut|last7=Borger|first7=Michael Andrew|last8=Carrel|first8=Thierry P.|last9=De Bonis|first9=Michele|last10=Evangelista|first10=Arturo|last11=Falk|first11=Volkmar|last12=Iung|first12=Bernard|last13=Lancellotti|first13=Patrizio|last14=Pierard|first14=Luc|last15=Price|first15=Susanna|last16=Schäfers|first16=Hans-Joachim|last17=Schuler|first17=Gerhard|last18=Stepinska|first18=Janina|last19=Swedberg|first19=Karl|last20=Takkenberg|first20=Johanna|last21=Von Oppell|first21=Ulrich Otto|last22=Windecker|first22=Stephan|last23=Zamorano|first23=Jose Luis|last24=Zembala|first24=Marian|last25=Bax|first25=Jeroen J.|last26=Baumgartner|first26=Helmut|last27=Ceconi|first27=Claudio|last28=Dean|first28=Veronica|last29=Deaton|first29=Christi|last30=Fagard|first30=Robert|last31=Funck-Brentano|first31=Christian|last32=Hasdai|first32=David|last33=Hoes|first33=Arno|last34=Kirchhof|first34=Paulus|last35=Knuuti|first35=Juhani|last36=Kolh|first36=Philippe|last37=McDonagh|first37=Theresa|last38=Moulin|first38=Cyril|last39=Popescu|first39=Bogdan A.|last40=Reiner|first40=Željko|last41=Sechtem|first41=Udo|last42=Sirnes|first42=Per Anton|last43=Tendera|first43=Michal|last44=Torbicki|first44=Adam|last45=Vahanian|first45=Alec|last46=Windecker|first46=Stephan|last47=Popescu|first47=Bogdan A.|last48=Von Segesser|first48=Ludwig|last49=Badano|first49=Luigi P.|last50=Bunc|first50=Matjaž|last51=Claeys|first51=Marc J.|last52=Drinkovic|first52=Niksa|last53=Filippatos|first53=Gerasimos|last54=Habib|first54=Gilbert|last55=Kappetein|first55=A. Pieter|last56=Kassab|first56=Roland|last57=Lip|first57=Gregory Y.H.|last58=Moat|first58=Neil|last59=Nickenig|first59=Georg|last60=Otto|first60=Catherine M.|last61=Pepper|first61=John|last62=Piazza|first62=Nicolo|last63=Pieper|first63=Petronella G.|last64=Rosenhek|first64=Raphael|last65=Shuka|first65=Naltin|last66=Schwammenthal|first66=Ehud|last67=Schwitter|first67=Juerg|last68=Mas|first68=Pilar Tornos|last69=Trindade|first69=Pedro T.|last70=Walther|first70=Thomas|title=Guidelines on the management of valvular heart disease (version 2012)|journal=European Heart Journal|volume=33|issue=19|year=2012|pages=2451–2496|issn=1522-9645|doi=10.1093/eurheartj/ehs109}}</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><ref name="pmid28298458">{{cite journal |vauthors=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM, Thompson A |title=2017 AHA/ACC Focused Update of the 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 Clinical Practice Guidelines |journal=Circulation |volume=135 |issue=25 |pages=e1159–e1195 |date=June 2017 |pmid=28298458 |doi=10.1161/CIR.0000000000000503 |url=}}</ref>==