BONOW ET AL., ACC/AHA TASK FORCE REPORT
JACC Vol. 32, No. 5, November 1998:1486-1588
ACC/AHA
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
(Committee on Management of Patients With Valvular Heart
Disease)
COMMITTEE
MEMBERS
Robert O. Bonow, MD, FACC, Chair, Blase Carabello,
MD, FACC, Antonio C. De Leon, Jr., MD, FACC, L. Henry
Edmunds, Jr., MD, FACC, Bradley J. Fedderly, MD, FAAFP,
Michael D. Freed, MD, FACC, William H. Gaasch, MD, FACC,
Charles R. Mckay, MD, FACC, Rick A. Nishimura, MD, FACC,
Patrick T. O'Gara, MD, FACC, Robert A. O'Rourke, MD,
FACC, Shahbudin H. Rahimtoola, MD, FACC
TASK
FORCE MEMBERS
James L. Ritchie, MD, FACC, Chair, Melvin D.
Cheitlin, MD, FACC, Kim A. Eagle, MD, FACC, Timothy
J. Gardner, MD, FACC, Arthur Garson, Jr., MD, MPH, FACC,
Raymond J. Gibbons, MD, FACC, Robert A. O'Rourke, MD,
FACC, Richard O. Russell, MD, FACC, Thomas J. Ryan,
MD, FACC, Sidney C. Smith, JR., MD, FACC
Contents
Preamble
and Introduction
II.
General Principles
-
A.
Evaluation of the Patient With a Cardiac Murmur
- 1.
Introduction
-
2.
Classification of Murmurs
- a.
Dynamic Cardiac Auscultation
- b.
Other Physical Findings
- c.
Associated Symptoms
- d.
Electrocardiography and Chest Roentgenography
- e.
Echocardiography
- f.
Cardiac Catheterization
3.
Approach to the Patient
B.
Endocarditis and Rheumatic Fever Prophylaxis
- 1.
Endocarditis Prophylaxis
-
2.
Rheumatic Fever Prophylaxis
- a.
General Considerations
- b.
Primary Prevention
- c.
Secondary Prevention
III.
Specific Valve Lesions
-
A.
Aortic Stenosis
-
1.
Introduction
- a.
Grading the Degree of Stenosis
- 2.
Pathophysiology
- 3.
Natural History
4.
Management of the Asymptomatic Patient
- a.
Initial Evaluation
- b.
Serial Testing
- c.
Medical Therapy
- d.
Physical Activity and Exercise
5.
Indications for Cardiac Catheterization
- a.
Low-Gradient Aortic Stenosis
6.
Indications for Aortic Valve Replacement
- a.
Symptomatic Patients
- b.
Asymptomatic Patients
- c.
Patients Undergoing Coronary Artery Bypass
Surgery
7.
Aortic Balloon Valvotomy
8. Medical Therapy
for the Inoperable Patient
9. Evaluation After
Aortic Valve Replacement
10. Special Considerations
in the Elderly
B.
Aortic Regurgitation
- 1.
Etiology
2.
Acute Aortic Regurgitation
- a.
Pathophysiology
- b.
Diagnosis
- c.
Treatment
3.
Chronic Aortic Regurgitation
- a.
Pathophysiology
-
b.
Natural History
- (1)
Asymptomatic Patients With Normal Lv Function
- (2)
Asymptomatic Patients With Depressed Systolic
Function
- (3)
Symptomatic Patients
- c.
Diagnosis and Initial Evaluation of the Asymptomatic
Patient
- d.
Medical Therapy
- e.
Physical Activity and Exercise
- f.
Serial Testing
- g.
Indications for Cardiac Catheterization
-
h.
Indications for Aortic Valve Replacement
- (1)
Symptomatic Patients With Normal Lv Systolic
Function
- (2)
Symptomatic Patients With Lv Dysfunction
- (3)
Asymptomatic Patients
4.
Concomitant Aortic Root Disease
5. Evaluation of
Patients After Aortic Valve Replacement 6.
Special Considerations in the Elderly
C.
Mitral Stenosis
- 1.
Pathophysiology and Natural History
2.
Evaluation and Management of the Asymptomatic
Patient
- a.
Initial Workup
- b.
Medical Therapy: General
- c.
Medical Therapy: Atrial Fibrillation
- d.
Medical Therapy: Prevention of Systemic Embolization
- e.
Recommendations Regarding Physical Activity
and Exercise
- f.
Serial Testing
3.
Evaluation of the Symptomatic Patient
- a.
Initial Workup
- b.
Indications for Cardiac Catheterization
4.
Indications for Surgical or Percutaneous Valvotomy
- 5.
Indications for Mitral Valve Replacement
- 6.
Management of Patients After Valvotomy or Commissurotomy
-
7.
Special Considerations
- a.
Pregnant Patients
- b.
Older Patients
D.
Mitral Valve Prolapse
- 1.
Pathophysiology and Natural History
- 2.
Evaluation and Management of the Asymptomatic
Patient
- 3.
Evaluation and Management of the Symptomatic Patient
- 4.
Surgical Considerations
E.
Mitral Regurgitation
- 1.
Etiology
-
2.
Acute Severe Mitral Regurgitation
- a.
Pathophysiology
- b.
Diagnosis
- c.
Medical Therapy
-
3.
Chronic Asymptomatic Mitral Regurgitation
- a.
Pathophysiology
- b.
Diagnosis
- c.
Serial Testing
- d.
Guidelines for Physical Activity and Exercise
- e.
Medical Therapy
- f.
Indications for Cardiac Catheterization
-
4.
Indications for Surgery
- a.
Types of Surgery
- b.
Timing of Surgery for Symptomatic Patients
With Normal Left Ventricular Function
- c.
Timing of Surgery in Asymptomatic or Symptomatic
Patients With Left Ventricular Dysfunction
- d.
Asymptomatic Patients with Normal Left Ventricular
Function
- e.
Atrial Fibrillation
- f.
Feasibility of Repair Versus Replacement
- 5.
Ischemic Mitral Regurgitation
- 6.
Evaluation of Patients After Mitral Valve Replacement
or Repair
- 7.
Special Considerations in the Elderly
-
F.
Multiple Valve Disease
- 1.
Introduction
-
2.
Mixed Single Valve Disease
- a.
Pathophysiology
-
b.
Diagnosis
- (1)
2-D and Doppler Echocardiographic Studies
- (2)
Cardiac Catheterization
- c.
Management
-
3.
Combined Mitral Stenosis and Aortic Regurgitation
- a.
Pathophysiology
- b.
Management
-
4.
Combined Mitral Stenosis and Tricuspid Regurgitation
- a.
Pathophysiology
- b.
Diagnosis
- c.
Management
-
5.
Combined Mitral and Aortic Regurgitation
- a.
Pathophysiology
- b.
Diagnosis and Therapy
-
6.
Combined Mitral and Aortic Stenosis
- a.
Pathophysiology
- b.
Diagnosis and Therapy
-
7.
Combined Aortic Stenosis and Mitral Regurgitation
- a.
Pathophysiology
- b.
Diagnosis and Therapy
-
G.
Tricuspid Valve Disease
- 1.
Pathophysiology
- 2.
Diagnosis
- 3.
Management
-
H.
Valvular Heart Disease Associated With Anorectic
Drugs
IV.
Evaluation and Management of Infective Endocarditis
- A.
Antimicrobial Therapy
- B.
Culture-Negative Endocarditis
- C.
Endocarditis in HIV-Seropositive Patients
- D.
Indications for Echocardiography in Endocarditis
- E.Outpatient
Treatment
- F.
Indications for Surgery in Patients With Active Infective
Endocarditis
V.
Management of Valvular Disease in Pregnancy
- A.
Physiological Changes of Pregnancy
- B.
Physical Examination
- C.
Echocardiography
- D.
General Management Guidelines
-
E.
Specific Lesions
- 1.
Mitral Stenosis
- 2.
Mitral Regurgitation
- 3.
Aortic Stenosis
- 4.
Aortic Regurgitation
- 5.
Pulmonary Valve Stenosis
- 6.
Tricuspid Valve Disease
- 7.
Marfan Syndrome
- F.
Endocarditis Prophylaxis
- G.
Cardiac Valve Surgery
-
H.
Anticoagulation
- 1.
Warfarin
- 2.
Heparin
VI.
Management of Valvular Heart Disease in Adolescents
and Young Adults
- A.
Aortic Stenosis
- B.
Aortic Regurgitation
- C.
Mitral Regurgitation
- D.
Mitral Stenosis
- E.
Tricuspid Valve Disease
-
F.
Pulmonic Stenosis
- 1.
Pathophysiology
- 2.
Diagnosis
- 3.
Clinical Course
- G.
Pulmonary Regurgitation
VII.
Management of Patients With Prosthetic Heart Valves
-
A.
Classification of Prosthetic Heart Valves
-
1.
Mechanical Valves
- a.
Ball Valves
- b.
Disk Valves
- c.
Bileaflet Valves
-
2.
Biological Valves
- a.
Autograft Valves
- b.
Autologous Pericardial Valves
- c.
Homograft (or Allograft) Valves
- d.
Porcine Heterograft (or Xenograft) Valves
- e.
Bovine Pericardial Valves
-
B.
Complications of Prosthetic Heart Valves
-
1.
Guidelines for Reporting Clinical Results
- a.
AATS/STS Guidelines for Clinical Reporting
-
2.
Valve-Related Complications
- a.
Major Randomized Trials
-
C.
Management of Patients With Prosthetic Heart Valves
-
1.
Antibiotic Prophylaxis
- a.
Infective Endocarditis
- b.
Recurrence of Rheumatic Carditis
-
2.
Antithrombotic Therapy
- a.
Mechanical Valves
- b.
Biological Valves
- c.
Difficulties in Maintaining Anticoagulant
Therapy
- d.
Embolic Events During Adequate Antithrombotic
Therapy
- e.
Excessive Anticoagulation
- f.
Antithrombotic Therapy in Patients Requiring
Noncardiac Surgery/Dental Care
- g.
Antithrombotic Therapy in Patients Needing
Cardiac Catheterization/Angiography
- h.
Thrombosis of Prosthetic Heart Valves
-
3.
Follow-up Visits
- a.
First Outpatient Postoperative Visit
- b.
Follow-up Visits in Patients Without Complications
- c.
Follow-up Visits in Patients With Complications
- 4.
Reoperation to Replace a Prosthetic Valve
- D.
Major Criteria for Valve Selection
VIII.
Evaluation and Treatment of Coronary Artery Disease
in Patients With Valvular Heart Disease
- A.
Probability of Coronary Artery Disease in Patients
With Valvular Heart Disease
- B.
Diagnosis of Coronary Artery Disease
- C.
Treatment of Coronary Artery Disease at the Time of
Aortic Valve Replacement
- D.
Aortic Valve Replacement in Patients Undergoing Coronary
Artery Bypass Surgery
- E.
Management of Concomitant Mitral Valve Disease and
Coronary Artery Disease
Abbreviations
and Acronyms
Tables
and Figures
References
When
citing this document, the American College of Cardiology
and the American Heart Association recommend that the
following format be used: Bonow RO, Carabello B, de
Leon AC Jr, Edmunds LH Jr, Fedderly BJ, Freed MD, Gaasch
WH, McKay CR, Nishimura RA, O'Gara PT, O'Rourke RA,
Rahimtoola SH. ACC/AHA 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 (Committee on Management
of Patients With Valvular Heart Disease). J Am Coll
Cardiol. 1998;32:1486-588.
Address
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©
1998 by the American College of Cardiology and the American
Heart Association, Inc.
Published by Elsevier Science.
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