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2017 AHA/ACC指南：心脏瓣膜病患者的管理（更新版）

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2017 AHA/ACC指南：心脏瓣膜病患者的管理（更新版）

Infective Endocarditis

Recommendation for IE Prophylaxis
Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:
1. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
3. Previous IE.
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve. （IIa）

Recommendations for Anticoagulation for Atrial Fibrillation (AF) in Patients With VHD
Anticoagulation with a vitamin K antagonist (VKA) is indicated for patients with rheumatic mitral stenosis (MS) and AF. （I）
Anticoagulation is indicated in patients with AF and a CHA2DS2-VASc score of 2 or greater with native aortic valve disease, tricuspid valve disease, or MR.(I)
It is reasonable to use a DOAC as an alternative to a VKA in patients with AF and native aortic valve disease, tricuspid valve disease, or MR and a CHA2DS2-VASc score of 2 or greater. (IIa)
Aortic Stenosis
Recommendations for Choice of Intervention
For patients in whom TAVR or high-risk surgical AVR is being considered, a heart valve team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care. (I)
Surgical AR is recommended for symptomatic patients with severe AS (Stage D) and asymptomatic patients with severe AS (Stage C) who meet an indication for AVR when surgical risk is low or intermediate. (I)
Surgical AVR or TAVR is recommended for symptomatic patients with severe AS (Stage D) and high risk for surgical AVR, depending on patient-specific procedural risks, values, and preferences. (I)
TAVR is recommended for symptomatic patients with severe AS (Stage D) and a prohibitive risk for surgical AVR who have a predicted post-TAVR survival greater than 12 months. (I)
TAVR is a reasonable alternative to surgical AVR for symptomatic patients with severe AS (Stage D) and an intermediate surgical risk,depending on patient-specific procedural risks, values, and preferences. (IIa)
Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR for symptomatic patients with severe AS. (IIb)
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS. (III: No Benefit)
Figure 1. Choice of TAVR Versus Surgical AVR in the Patient With Severe Symptomatic AS

Mitral Regurgitation
Table 2. Stages of Secondary MR

Intervention: Recommendations
Mitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30%. (I)
Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2). (I)
Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet. (I)
Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished. (I)
Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications. (I)
Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a Heart Valve Center of Excellence. (IIa)
Mitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) with a progressive increase in LV size or decrease in ejection fraction (EF) on serial imaging studies. (IIa)
Mitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg). (IIa)
Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications. (IIa)
Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30% (stage D). (IIb)
Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for heart failure (HF). (IIb)
MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful. (III:Harm)
Figure 2. Indications for Surgery for MR (Updated Figure 4 From the 2014 VHD guideline)

Chronic Secondary MR
Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR. (IIa)
It is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF. (IIa)
Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF. (IIb)
In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG,the usefulness of mitral valve repair is uncertain. (IIb)

Prosthetic Valves
The choice of type of prosthetic heart valve should be a shared decisionmaking process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risk associated with reintervention. (I)
A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired. (I)
An aortic or mitral mechanical prosthesis is reasonable for patients less than 50 years of age who do not have a contraindication to anticoagulation. (IIa)
For patients between 50 and 70 years of age,it is reasonable to individualize the choice of either a mechanical or bioprosthetic valve prosthesis on the basis of individual patient factors and preferences, after full discussion of the trade-offs involved. (IIa)
A bioprosthesis is reasonable for patients more than 70 years of age. (IIa)
Replacement of the aortic valve by a pulmonary autograft (the Ross procedure),when performed by an experienced surgeon,may be considered for young patients when VKA anticoagulation is contraindicated or undesirable. (IIb)
Table 3. Factors Used for Shared Decision Making About Type of Valve Prosthesis