doi:10.1016/j.jacc.2006.05.021 2006;48;1-148 J. Am. Coll. Cardiol. Nishimura, Richard L. Page ...

151 Pages·2006·5.26 MB·English

ACC/AHA 2006 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 (Writing Committee to
Revise the 1998 Guidelines for the Management of Patients With Valvular
Heart Disease) Developed in Collaboration With the Society of Cardiovascular
Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and
Interventions and the Society of Thoracic Surgeons
Robert O. Bonow, Blase A. Carabello, Kanu Chatterjee, Antonio C. de Leon, Jr,
David P. Faxon, Michael D. Freed, William H. Gaasch, Bruce Whitney Lytle, Rick
A. Nishimura, Patrick T. O’Gara, Robert A. O’Rourke, Catherine M. Otto, Pravin
M. Shah, Jack S. Shanewise, Sidney C. Smith, Jr, Alice K. Jacobs, Cynthia D.
Adams, Jeffrey L. Anderson, Elliott M. Antman, David P. Faxon, Valentin Fuster,
Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce W. Lytle, Rick
Nishimura, Richard L. Page and Barbara Riegel
J. Am. Coll. Cardiol. 2006;48;1-148
doi:10.1016/j.jacc.2006.05.021
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This information is current as of September 1, 2006
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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JournaloftheAmericanCollegeofCardiology Vol.48,No.3,2006
©2006bytheAmericanCollegeofCardiologyFoundationandtheAmericanHeartAssociation,Inc. ISSN0735-1097/06/$32.00
PublishedbyElsevierInc. doi:10.1016/j.jacc.2006.05.021
ACC/AHA PRACTICE GUIDELINES
ACC/AHA 2006 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 (Writing Committee
to Revise the 1998 Guidelines for the Management of Patients
With Valvular Heart Disease)
Developed in Collaboration With the Society of Cardiovascular Anesthesiologists
Endorsed by the Society for Cardiovascular Angiography and Interventions and
the Society of Thoracic Surgeons
WRITING COMMITTEE MEMBERS
Robert O. Bonow, MD, FACC, FAHA, Chair
Blase A. Carabello, MD, FACC, FAHA Bruce Whitney Lytle, MD, FACC
Kanu Chatterjee, MB, FACC Rick A. Nishimura, MD, FACC, FAHA
Antonio C. de Leon, JR, MD, FACC, FAHA Patrick T. O’Gara, MD, FACC, FAHA
David P. Faxon, MD, FACC, FAHA Robert A. O’Rourke, MD, MACC, FAHA
Michael D. Freed, MD, FACC, FAHA Catherine M. Otto, MD, FACC, FAHA
William H. Gaasch, MD, FACC, FAHA Pravin M. Shah, MD, MACC, FAHA
Jack S. Shanewise, MD*
*SocietyofCardiovascularAnesthesiologistsRepresentative
TASK FORCE MEMBERS
Sidney C. Smith, JR, MD, FACC, FAHA, Chair
Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair
Cynthia D. Adams, MSN, APRN-BC, FAHA Loren F. Hiratzka, MD, FACC, FAHA‡
Jeffrey L. Anderson, MD, FACC, FAHA Sharon A. Hunt, MD, FACC, FAHA
Elliott M. Antman, MD, FACC, FAHA† Bruce W. Lytle, MD, FACC, FAHA
David P. Faxon, MD, FACC, FAHA‡ Rick Nishimura, MD, FACC, FAHA
Valentin Fuster, MD, PHD, FACC, FAHA‡ Richard L. Page, MD, FACC, FAHA
Jonathan L. Halperin, MD, FACC, FAHA Barbara Riegel, DNSC, RN, FAHA
†ImmediatePastChair;‡FormerTaskForcememberduringthiswritingeffort
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyFoundationBoardofTrusteesinMay2006andbytheAmericanHeartAssociationScienceAdvisoryand
CoordinatingCommitteeinMay2006.
Whencitingthisdocument,theAmericanCollegeofCardiologyFoundationrequeststhatthefollowingcitationformatbeused:BonowRO,CarabelloBA,ChatterjeeK,deLeon
ACJr.,FaxonDP,FreedMD,GaaschWH,LytleBW,NishimuraRA,O’GaraPT,O’RourkeRA,OttoCM,ShahPM,ShanewiseJS.ACC/AHA2006guidelinesforthe
managementofpatientswithvalvularheartdisease:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(WritingCommittee
toDevelopGuidelinesfortheManagementofPatientsWithValvularHeartDisease).AmericanCollegeofCardiologyWebSite.Availableat:http://www.acc.org/clinical/guidelines/
valvular/index.pdf.
ThisarticlehasbeencopublishedintheAugust1,2006issueofCirculation.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanCollegeofCardiology(www.acc.org)andtheAmericanHeartAssociation(www.my.american-
heart.org).Singlecopiesoftheexecutivesummaryareavailablebycalling1-800-253-4636orwritingtheAmericanCollegeofCardiologyFoundation,ResourceCenter,at9111Old
GeorgetownRoad,Bethesda,MD20814-1699.Topurchasebulkreprints,fax:[phone],ore-mail:[email protected].
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpresspermissionoftheAmericanHeart
[e-mail].
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e2 Bonowetal. JACCVol.48,No.3,2006
ACC/AHAPracticeGuidelines August1,2006:e1–148
TABLE OF CONTENTS 3.2.3.1. Pathophysiology................................e28
3.2.3.2. NaturalHistory.................................e29
PREAMBLE..............................................................................e4
3.2.3.2.1. AsymptomaticPatients
WithNormalLeft
1. INTRODUCTION.............................................................e5
VentricularFunction........e29
1.1. OrganizationoftheCommitteeandEvidence
3.2.3.2.2. AsymptomaticPatients
Review..........................................................................e5
WithDepressedSystolic
1.2. ScopeoftheDocument...............................................e6
Function...........................e32
2. GENERALPRINCIPLES................................................e8 3.2.3.2.3. SymptomaticPatients......e32
2.1. EvaluationofthePatientWithaCardiacMurmur...e8 3.2.3.3. DiagnosisandInitialEvaluation......e32
2.1.1. Introduction......................................................e8 3.2.3.4. MedicalTherapy...............................e33
2.1.2. ClassificationofMurmurs................................e8 3.2.3.5. PhysicalActivityandExercise..........e35
2.1.2.1. DynamicCardiacAuscultation...........e9 3.2.3.6. SerialTesting....................................e35
2.1.2.2. OtherPhysicalFindings.....................e9 3.2.3.7. IndicationsforCardiac
2.1.2.3. AssociatedSymptoms.......................e10 Catheterization..................................e36
2.1.3. ElectrocardiographyandChest 3.2.3.8. IndicationsforAorticValveReplacement
Roentgenography............................................e11 orAorticValveRepair..........................e37
2.1.4. Echocardiography............................................e11 3.2.3.8.1. SymptomaticPatients
2.1.5. CardiacCatheterization..................................e12 WithNormalLeft
2.1.6. ExerciseTesting..............................................e12 VentricularSystolic
2.1.7. ApproachtothePatient.................................e12 Function...........................e37
2.2. ValveDiseaseSeverityTable.....................................e13 3.2.3.8.2. SymptomaticPatients
2.3. EndocarditisandRheumaticFeverProphylaxis........e13 WithLeftVentricular
2.3.1. EndocarditisProphylaxis.................................e13 Dysfunction......................e37
2.3.2. RheumaticFeverProphylaxis.........................e16 3.2.3.8.3. AsymptomaticPatients....e38
2.3.2.1. GeneralConsiderations.....................e16 3.2.4. ConcomitantAorticRootDisease.................e39
2.3.2.2. PrimaryPrevention...........................e16 3.2.5. EvaluationofPatientsAfterAorticValve
2.3.2.3. SecondaryPrevention........................e17 Replacement....................................................e39
3.2.6. SpecialConsiderationsintheElderly............e40
3. SPECIFICVALVELESIONS.......................................e17 3.3. BicuspidAorticValveWithDilatedAscending
3.1. AorticStenosis...........................................................e17 Aorta...........................................................................e40
3.1.1. Introduction....................................................e17 3.4. MitralStenosis...........................................................e41
3.1.1.1. GradingtheDegreeofStenosis.......e18 3.4.1. PathophysiologyandNaturalHistory............e41
3.1.2. Pathophysiology..............................................e19 3.4.2. IndicationsforEchocardiographyinMitral
3.1.3. NaturalHistory...............................................e20 Stenosis............................................................e42
3.1.4. ManagementoftheAsymptomaticPatient...e20 3.4.3. MedicalTherapy.............................................e45
3.1.4.1. Echocardiography(Imaging, 3.4.3.1. MedicalTherapy:General................e45
Spectral,andColorDoppler)in 3.4.3.2. MedicalTherapy:Atrial
AorticStenosis..................................e20 Fibrillation.........................................e45
3.1.4.2. ExerciseTesting................................e22 3.4.3.3. MedicalTherapy:Preventionof
3.1.4.3. SerialEvaluations..............................e22 SystemicEmbolization......................e46
3.1.4.4. MedicalTherapy...............................e22 3.4.4 RecommendationsRegardingPhysicalActivity
3.1.4.5. PhysicalActivityandExercise..........e23 andExercise....................................................e46
3.1.5. IndicationsforCardiacCatheterization.........e23 3.4.5. SerialTesting..................................................e47
3.1.6. Low-Flow/Low-GradientAorticStenosis.....e23 3.4.6. EvaluationoftheSymptomaticPatient.........e47
3.1.7. IndicationsforAorticValveReplacement.....e24 3.4.7. IndicationsforInvasiveHemodynamic
3.1.7.1. SymptomaticPatients.......................e25 Evaluation.......................................................e47
3.1.7.2. AsymptomaticPatients.....................e25 3.4.8. IndicationsforPercutaneousMitralBalloon
3.1.7.3. PatientsUndergoingCoronaryArtery Valvotomy.......................................................e50
BypassorOtherCardiacSurgery.....e26 3.4.9. IndicationsforSurgeryforMitralStenosis....e53
3.1.8. AorticBalloonValvotomy..............................e26 3.4.10. ManagementofPatientsAfterValvotomyor
3.1.9. MedicalTherapyfortheInoperablePatient..e27 Commissurotomy............................................e54
3.1.10. EvaluationAfterAorticValveReplacement..e27 3.4.11. SpecialConsiderations....................................e55
3.1.11. SpecialConsiderationsintheElderly............e27 3.4.11.1. PregnantPatients..............................e55
3.2. AorticRegurgitation..................................................e27 3.4.11.2. OlderPatients...................................e55
3.2.1. Etiology...........................................................e27 3.5. MitralValveProlapse.................................................e55
3.2.2. AcuteAorticRegurgitation............................e28 3.5.1. PathophysiologyandNaturalHistory............e55
3.2.2.1. Pathophysiology................................e28 3.5.2. EvaluationandManagementofthe
3.2.2.2. Diagnosis...........................................e28 AsymptomaticPatient.....................................e56
3.2.2.3. Treatment..........................................e28 3.5.3. EvaluationandManagementofthe
3.2.3. ChronicAorticRegurgitation.........................e28 SymptomaticPatient.......................................e57
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3.5.4. SurgicalConsiderations...................................e59 3.7.5. CombinedMitralRegurgitationandAortic
3.6. MitralRegurgitation..................................................e59 Regurgitation...................................................e69
3.6.1. Etiology...........................................................e59 3.7.5.1. Pathophysiology................................e69
3.6.2. AcuteSevereMitralRegurgitation.................e59 3.7.5.2. DiagnosisandTherapy.....................e70
3.6.2.1. Pathophysiology................................e59 3.7.6. CombinedMitralStenosisandAortic
3.6.2.2. Diagnosis...........................................e59 Stenosis............................................................e70
3.6.2.3. MedicalTherapy...............................e59 3.7.6.1. Pathophysiology................................e70
3.6.3. ChronicAsymptomaticMitral 3.7.6.2. DiagnosisandTherapy.....................e70
Regurgitation...................................................e60 3.7.7. CombinedAorticStenosisandMitral
3.6.3.1. PathophysiologyandNatural Regurgitation...................................................e70
History..............................................e60 3.7.7.1. Pathophysiology................................e70
3.6.3.2. Diagnosis...........................................e60 3.7.7.2. DiagnosisandTherapy.....................e70
3.6.3.3. IndicationsforTransthoracic 3.8. TricuspidValveDisease.............................................e70
Echocardiography..............................e60 3.8.1. Pathophysiology..............................................e70
3.6.3.4. IndicationsforTransesophageal 3.8.2. Diagnosis.........................................................e71
Echocardiography..............................e61 3.8.3. Management...................................................e71
3.6.3.5. SerialTesting....................................e61 3.9. Drug-RelatedValvularHeartDisease.......................e72
3.6.3.6. GuidelinesforPhysicalActivity 3.10. RadiationHeartDisease............................................e72
andExercise......................................e62
3.6.3.7. MedicalTherapy...............................e62 4. EVALUATIONANDMANAGEMENTOF
3.6.3.8. IndicationsforCardiac INFECTIVEENDOCARDITIS....................................e73
Catheterization..................................e62 4.1. AntimicrobialTherapy...............................................e73
3.6.4. IndicationsforSurgery....................................e63 4.2. Culture-NegativeEndocarditis..................................e74
3.6.4.1. TypesofSurgery...............................e63 4.3. EndocarditisinHIV-SeropositivePatients...............e76
3.6.4.2. IndicationsforMitralValve 4.4. IndicationsforEchocardiographyinSuspectedor
Operation..........................................e63 KnownEndocarditis..................................................e76
3.6.4.2.1. SymptomaticPatients 4.4.1. TransthoracicEchocardiographyin
WithNormalLeft Endocarditis....................................................e77
VentricularFunction........e64 4.4.2. TransesophagealEchocardiographyin
3.6.4.2.2. Asymptomaticor Endocarditis....................................................e78
SymptomaticPatients 4.5. OutpatientTreatment................................................e80
WithLeftVentricular 4.6. IndicationsforSurgeryinPatientsWithAcute
Dysfunction......................e64 InfectiveEndocarditis................................................e80
3.6.4.2.3. AsymptomaticPatients 4.6.1. SurgeryforNativeValveEndocarditis...........e82
WithNormalLeft 4.6.2. SurgeryforProstheticValveEndocarditis.....e82
VentricularFunction........e66
3.6.4.2.4. AtrialFibrillation.............e66 5. MANAGEMENTOFVALVULARDISEASEIN
3.6.5. IschemicMitralRegurgitation........................e67 PREGNANCY..................................................................e83
3.6.6. EvaluationofPatientsAfterMitralValve 5.1. PhysiologicalChangesofPregnancy.........................e83
ReplacementorRepair....................................e67 5.2. PhysicialExamination................................................e83
3.6.7. SpecialConsiderationsintheElderly............e67 5.3. Echocardiography.......................................................e83
3.7. MultipleValveDisease..............................................e67 5.4. GeneralManagementGuidelines..............................e84
3.7.1. Introduction....................................................e67 5.5. SpecificLesions..........................................................e84
3.7.2. MixedSingleValveDisease...........................e68 5.5.1. MitralStenosis................................................e84
3.7.2.1. Pathophysiology................................e68 5.5.2. MitralRegurgitation.......................................e86
3.7.2.2. Diagnosis...........................................e68 5.5.3. AorticStenosis................................................e86
3.7.2.2.1. Two-Dimensionaland 5.5.4. AorticRegurgitation.......................................e87
DopplerEchocardiographic 5.5.5. PulmonicStenosis...........................................e87
Studies..............................e68 5.5.6. TricuspidValveDisease..................................e87
3.7.2.2.2. CardiacCatheterization...e68 5.5.7. MarfanSyndrome...........................................e87
3.7.2.3. Management.....................................e69 5.6. EndocarditisProphylaxis............................................e87
3.7.3. CombinedMitralStenosisandAortic 5.7. CardiacValveSurgery................................................e88
Regurgitation...................................................e69 5.8. AnticoagulationDuringPregnancy...........................e88
3.7.3.1. Pathophysiology................................e69 5.8.1. Warfarin..........................................................e88
3.7.3.2. Management.....................................e69 5.8.2. UnfractionatedHeparin..................................e88
3.7.4. CombinedMitralStenosisandTricuspid 5.8.3. Low-Molecular-WeightHeparins..................e88
Regurgitation...................................................e69 5.8.4. SelectionofAnticoagulationRegimenin
3.7.4.1. Pathophysiology................................e69 PregnantPatientsWithMechanical
3.7.4.2. Diagnosis...........................................e69 ProstheticValves.............................................e89
3.7.4.3. Management.....................................e69 5.9. SelectionofValveProsthesesinYoungWomen......e90
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e4 Bonowetal. JACCVol.48,No.3,2006
ACC/AHAPracticeGuidelines August1,2006:e1–148
6. MANAGEMENTOFCONGENITALVALVULAR 8.1.1. AorticStenosis..............................................e110
HEARTDISEASEINADOLESCENTSAND 8.1.2. AorticRegurgitation.....................................e110
YOUNGADULTS...........................................................e90 8.1.3. MitralStenosis..............................................e110
6.1. AorticStenosis...........................................................e91 8.1.4. MitralRegurgitation.....................................e111
6.1.1. Pathophysiology..............................................e91 8.1.5. TricuspidRegurgitation................................e111
6.1.2. EvaluationofAsymptomaticAdolescentsor 8.1.6. TricuspidStenosis.........................................e111
YoungAdultsWithAorticStenosis..............e91 8.1.7. PulmonicValveLesions................................e111
6.1.3. IndicationsforAorticBalloonValvotomyin 8.2. SpecificClinicalScenarios.......................................e111
AdolescentsandYoungAdults.......................e92 8.2.1. PreviouslyUndetectedAorticStenosisDuring
6.2. AorticRegurgitation..................................................e93 CABG...........................................................e111
6.3. MitralRegurgitation..................................................e94 8.2.2. PreviouslyUndetectedMitralRegurgitation
6.4. MitralStenosis...........................................................e95 DuringCABG..............................................e111
6.5. TricuspidValveDisease.............................................e95
9. MANAGEMENTOFPATIENTSWITH
6.5.1. Pathophysiology..............................................e95
PROSTHETICHEARTVALVES..............................e112
6.5.2. EvaluationofTricuspidValveDiseasein
9.1. AntibioticProphylaxis..............................................e112
AdolescentsandYoungAdults.......................e96
9.1.1. InfectiveEndocarditis...................................e112
6.5.3. IndicationsforInterventioninTricuspid
9.1.2. RecurrenceofRheumaticCarditis................e112
Regurgitation...................................................e96
9.2. AntithromboticTherapy..........................................e112
6.6. PulmonicStenosis......................................................e97
9.2.1. MechanicalValves.........................................e113
6.6.1. Pathophysiology..............................................e97
9.2.2. BiologicalValves...........................................e114
6.6.2. EvaluationofPulmonicStenosisin
9.2.3. EmbolicEventsDuringAdequate
AdolescentsandYoungAdults.......................e97
AntithromboticTherapy...............................e114
6.6.3. IndicationsforBalloonValvotomyin
9.2.4. ExcessiveAnticoagulation.............................e114
PulmonicStenosis...........................................e97
9.2.5. BridgingTherapyinPatientsWithMechanical
6.7. PulmonaryRegurgitation...........................................e98
ValvesWhoRequireInterruptionofWarfarin
7. SURGICALCONSIDERATIONS................................e99 TherapyforNoncardiacSurgery,Invasive
7.1. AmericanAssociationforThoracicSurgery/ Procedures,orDentalCare..........................e114
SocietyofThoracicSurgeonsGuidelinesforClinical 9.2.6. AntithromboticTherapyinPatientsWhoNeed
ReportingofHeartValveComplications..................e99 CardiacCatheterization/Angiography..........e115
7.2. AorticValveSurgery................................................e101 9.2.7. ThrombosisofProstheticHeartValves.......e115
7.2.1. RisksandStrategiesinAorticValveSurgery..e101 9.3. Follow-UpVisits......................................................e116
7.2.2. MechanicalAorticValveProstheses.............e101 9.3.1. FirstOutpatientPostoperativeVisit.............e117
7.2.2.1. AntithromboticTherapyforPatients 9.3.2. Follow-UpVisitsinPatientsWithout
WithAorticMechanicalHeartValves.e101 Complications...............................................e117
7.2.3. StentedandNonstentedHeterografts..........e102 9.3.3. Follow-UpVisitsinPatientsWith
7.2.3.1. AorticValveReplacementWith Complications...............................................e117
StentedHeterografts.......................e102 9.4. ReoperationtoReplaceaProstheticValve.............e118
7.2.3.2. AorticValveReplacementWith
10. EVALUATIONANDTREATMENTOFCORONARY
StentlessHeterografts.....................e102
ARTERYDISEASEINPATIENTSWITH
7.2.4. AorticValveHomografts..............................e102
VALVULARHEARTDISEASE.................................e118
7.2.5. PulmonicValveAutotransplantation............e104
10.1. ProbabilityofCoronaryArteryDiseaseinPatients
7.2.6. AorticValveRepair......................................e104
WithValvularHeartDisease...................................e118
7.2.7. LeftVentricle–to–DescendingAortaShunt.e104
10.2. DiagnosisofCoronaryArteryDisease....................e119
7.2.8. ComparativeTrialsandSelectionofAortic
10.3. TreatmentofCoronaryArteryDiseaseattheTimeof
ValveProstheses............................................e104
AorticValveReplacement.......................................e120
7.2.9. MajorCriteriaforAorticValveSelection....e105
10.4. AorticValveReplacementinPatientsUndergoing
7.3. MitralValveSurgery................................................e106
CoronaryArteryBypassSurgery..............................e120
7.3.1. MitralValveRepair......................................e106
10.5. ManagementofConcomitantMitralValveDisease
7.3.1.1. MyxomatousMitralValve..............e106
andCoronaryArteryDisease...................................e121
7.3.1.2. RheumaticHeartDisease...............e107
APPENDIX1.........................................................................e121
7.3.1.3. IschemicMitralValveDisease.......e107
APPENDIX2.........................................................................e122
7.3.1.4. MitralValveEndocarditis...............e107
APPENDIX3.........................................................................e124
7.3.2. MitralValveProstheses(Mechanicalor
REFERENCES......................................................................e124
Bioprostheses)...............................................e107
7.3.2.1. SelectionofaMitralValve
PREAMBLE
Prosthesis.........................................e108
7.4. TricuspidValveSurgery...........................................e108 Itisimportantthatthemedicalprofessionplayasignificant
7.5. ValveSelectionforWomenofChildbearingAge......e109
role in critically evaluating the use of diagnostic procedures
8. INTRAOPERATIVEASSESSMENT.........................e109 and therapies as they are introduced in the detection,
8.1. SpecificValveLesions..............................................e110 management, or prevention of disease states. Rigorous and
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August1,2006:e1–148 ACC/AHAPracticeGuidelines
expert analysis of the available data documenting the abso- andhttp://circ.ahajournals.org/manual).SeeAppendix1fora
lute and relative benefits and risks of those procedures and list of writing committee member relationships with industry
therapies can produce helpful guidelines that improve the andAppendix2foralistingofpeerreviewerrelationshipswith
effectiveness of care, optimize patient outcomes, and favor- industrythatarepertinenttothisguideline.
ably affect the overall cost of care by focusing resources on Thesepracticeguidelinesareintendedtoassisthealthcare
the most effective strategies. providers in clinical decision making by describing a range
The American College of Cardiology (ACC) and the of generally acceptable approaches for the diagnosis, man-
American Heart Association (AHA) have jointly engaged agement, and prevention of specific diseases or conditions.
in the production of such guidelines in the area of cardio- These guidelines attempt to define practices that meet the
vascular disease since 1980. This effort is directed by the needsofmostpatientsinmostcircumstances.Theseguide-
ACC/AHA Task Force on Practice Guidelines, whose line recommendations reflect a consensus of expert opinion
chargeistodevelop,update,orrevisepracticeguidelinesfor after a thorough review of the available, current scientific
important cardiovascular diseases and procedures. Writing evidence and are intended to improve patient care. If these
committees are charged with the task of performing an guidelines are used as the basis for regulatory/payer deci-
assessment of the evidence and acting as an independent sions, the ultimate goal is quality of care and serving the
groupofauthorstodevelopandupdatewrittenrecommen- patient’s best interests. The ultimate judgment regarding
dations for clinical practice. care of a particular patient must be made by the healthcare
Experts in the subject under consideration are selected provider and patient in light of all of the circumstances
from both organizations to examine subject-specific data presentedbythatpatient.Therearecircumstancesinwhich
and write guidelines. The process includes additional rep- deviations from these guidelines are appropriate.
resentatives from other medical practitioner and specialty The “ACC/AHA 2006 Guideline for the Management
groups where appropriate. Writing committees are specifi- ofPatientsWithValvularHeartDisease”wasapprovedfor
cally charged to perform a formal literature review, weigh publication by the ACC Foundation (ACCF) board of
thestrengthofevidencefororagainstaparticulartreatment trustees in May 2006 and the AHA Science Advisory and
or procedure, and include estimates of expected health Coordinating Committee in May 2006. The executive
outcomes where data exist. Patient-specific modifiers, co- summaryandrecommendationsarepublishedintheAugust
morbidities, and issues of patient preference that might 1, 2006 issue of the Journal of the American College of
influence the choice of particular tests or therapies are CardiologyandtheAugust1,2006issueofCirculation.The
considered, as well as frequency of follow-up. When avail- full-text guideline is e-published in the same issues of each
able, information from studies on cost will be considered; journal and is posted on the World Wide Web sites of the
however, review of data on efficacy and clinical outcomes ACC (www.acc.org) and the AHA (www.american-
will be the primary basis for preparing recommendation in heart.org). The guidelines will be reviewed annually by the
these guidelines. ACC/AHATaskForceonPracticeGuidelinesandwillbe
The ACC/AHA Task Force on Practice Guidelines considered current unless they are updated, revised, or
makes every effort to avoid any actual, potential, or per- sunsetted and withdrawn from distribution. Copies of the
ceived conflicts of interest that might arise as a result of an fulltextandtheexecutivesummaryareavailablefromboth
outsiderelationshiporpersonalinterestofamemberofthe organizations.
writing committee. Specifically, all members of the writing Sidney C. Smith, Jr., MD, FACC, FAHA,
committeeandpeerreviewersofthedocumentareaskedto Chair, ACC/AHA Task Force on Practice Guidelines
provide disclosure statements of all such relationships that
might be perceived as real or potential conflicts of interest.
1. INTRODUCTION
Writing committee members are also strongly encouraged
to declare a previous relationship with industry that might
1.1. Organization of the Committee and Evidence Review
be perceived as relevant to guideline development. If a
writing committee member develops a new relationship The ACC and the AHA have long been involved in the
withindustryduringhisorhertenure,heorsheisrequired joint development of practice guidelines designed to assist
to notify guideline staff in writing. The continued partici- healthcare providers in the management of selected cardio-
pation of the writing committee member will be reviewed. vascular disorders or the selection of certain cardiovascular
These statements are reviewed by the parent task force, procedures. The determination of the disorders or proce-
reported orally to all members of the writing panel at each dures to develop guidelines for is based on several factors,
meeting,andupdatedandreviewedbythewritingcommit- including importance to healthcare providers and whether
tee as changes occur. Please refer to the methodology there are sufficient data from which to derive accepted
manual for the ACC/AHA guideline writing committees guidelines.Oneimportantcategoryofcardiacdisordersthat
for further description and the relationships with industry affect a large number of patients who require diagnostic
policy,availableonACCandAHAWorldWideWebsites proceduresanddecisionsregardinglong-termmanagement
(http://www.acc.org/clinical/manual/manual_introltr.htm is valvular heart disease.
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e6 Bonowetal. JACCVol.48,No.3,2006
ACC/AHAPracticeGuidelines August1,2006:e1–148
Duringthepast2decades,majoradvanceshaveoccurredin Classification of recommendations and level of evidence
diagnostic techniques, the understanding of natural history, are expressed in the ACC/AHA format as follows:
and interventional cardiology and surgical procedures for pa- • Class I: Conditions for which there is evidence for
tientswithvalvularheartdisease.Theseadvanceshaveresulted
and/or general agreement that the procedure or treat-
inenhanceddiagnosis,morescientificselectionofpatientsfor
ment is beneficial, useful, and effective.
surgeryorcatheter-basedinterventionversusmedicalmanage- • Class II: Conditions for which there is conflicting
ment, and increased survival of patients with these disorders.
evidence and/or a divergence of opinion about the
The information base from which to make clinical manage-
usefulness/efficacy of a procedure or treatment.
ment decisions has greatly expanded in recent years, yet in • Class IIa: Weight of evidence/opinion is in favor of
many situations, management issues remain controversial or
usefulness/efficacy.
uncertain.Unlikemanyotherformsofcardiovasculardisease, • Class IIb: Usefulness/efficacy is less well established
thereisascarcityoflarge-scalemulticentertrialsaddressingthe
by evidence/opinion.
diagnosisandtreatmentofpatientswithvalvulardiseasefrom • ClassIII:Conditionsforwhichthereisevidenceand/or
which to derive definitive conclusions, and the information
general agreement that the procedure/treatment is not
available in the literature represents primarily the experiences
useful/effective and in some cases may be harmful.
reported by single institutions in relatively small numbers of
patients.
In addition, the weight of evidence in support of the
The 1998 Committee on Management of Patients With
recommendation is listed as follows:
Valvular Heart Disease reviewed and compiled this informa-
tion base and made recommendations for diagnostic testing, • Level of Evidence A: Data derived from multiple
treatment,andphysicalactivity.Fortopicsforwhichtherewas randomized clinical trials.
an absence of multiple randomized, controlled trials, the • Level of Evidence B: Data derived from a single
preferredbasisformedicaldecisionmakinginclinicalpractice randomized trial or nonrandomized studies.
(evidence-basedmedicine),thecommittee’srecommendations • Level of Evidence C: Only consensus opinion of ex-
werebasedondataderivedfromsinglerandomizedtrialsor perts, case studies, or standard-of-care.
nonrandomized studies or were based on a consensus
The schema for classification of recommendations and
opinion of experts. The current writing committee was
level of evidence is summarized in Figure 1, which also
chargedwithrevisingtheguidelinespublishedin1998.The
illustrates how the grading system provides an estimate of
committee reviewed pertinent publications, including ab-
the size of the treatment effect and an estimate of the
stracts, through a computerized search of the English
certainty of the treatment effect.
literaturesince1998andperformedamanualsearchoffinal
Writing committee membership consisted of cardiovas-
articles. Special attention was devoted to identification of
cular disease specialists and representatives of the cardiac
randomizedtrialspublishedsincetheoriginaldocument.A
surgeryandcardiacanesthesiologyfields;boththeacademic
completelistingofallpublicationscoveringthetreatmentof
andprivatepracticesectorswererepresented.TheSocietyof
valvularheartdiseaseisbeyondthescopeofthisdocument;
Cardiovascular Anesthesiologists assigned an official repre-
the document includes those reports that the committee
sentative to the writing committee.
believes represent the most comprehensive or convincing
This document was reviewed by 2 official reviewers
datathatarenecessarytosupportitsconclusions.However,
nominated by the ACC; 2 official reviewers nominated by
evidencetableswereupdatedtoreflectmajoradvancesover
the AHA; 1 official reviewer from the ACC/AHA Task
this time period. Inaccuracies or inconsistencies present in
Force on Practice Guidelines; reviewers nominated by the
theoriginalpublicationwereidentifiedandcorrectedwhen
SocietyofCardiovascularAnesthesiologists,theSocietyfor
possible. Recommendations provided in this document are
Cardiovascular Angiography and Interventions, and the
based primarily on published data. Because randomized
SocietyofThoracicSurgeons(STS);andindividualcontent
trialsareunavailableinmanyfacetsofvalvularheartdisease
reviewers, including members of the ACCF Cardiac Cath-
treatment, observational studies and, in some areas, expert
eterizationandInterventionCommittee,ACCFCardiovas-
opinionsformthebasisforrecommendationsthatareoffered.
cular Imaging Committee, ACCF Cardiovascular Surgery
All of the recommendations in this guideline revision
Committee,AHAEndocarditisCommittee,AHACardiac
were converted from the tabular format used in the 1998
Clinical Imaging Committee, AHA Cardiovascular Inter-
guideline to a listing of recommendations that has been
ventionandImagingCommittee,andAHACerebrovascu-
writteninfullsentencestoexpressacompletethought,such
lar Imaging and Intervention Committee.
that a recommendation, even if separated and presented
apartfromtherestofthedocument,wouldstillconveythe 1.2. Scope of the Document
fullintentoftherecommendation.Itishopedthatthiswill
increasethereaders’comprehensionoftheguidelines.Also, The guidelines attempt to deal with general issues of
the level of evidence, either A, B, or C, for each recom- treatment of patients with heart valve disorders, such as
mendation is now provided. evaluation of patients with heart murmurs, prevention and
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Figure1. Applyingclassificationofrecommendationsandlevelofevidence.*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchasgender, Gn
uo
age,historyofdiabetes,historyofpriormyocardialinfarction,historyofheartfailure,andprioraspirinuse.ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendation idw
isweak.Manyimportantclinicalquestionsaddressedintheguidelinesdonotlendthemselvestoclinicaltrials.Eventhoughrandomizedtrialsarenotavailable,theremaybeaveryclearclinical elinet
consensus that a particular test or therapy is useful or effective. †In 2003 the ACC/AHA Task Force on Practice Guidelines recently provided a list of suggested phrases to use when writing ea
sl.
recommendations.Allrecommendationsinthisguidelinehavebeenwritteninfullsentencesthatexpressacompletethought,suchthatarecommendation,evenifseparatedandpresentedapart
fromtherestofthedocument(includingheadingsabovesetsofrecommendations),wouldstillconveythefullintentoftherecommendation.Itishopedthatthiswillincreasereaders’comprehension
oftheguidelinesandwillallowqueriesattheindividualrecommendationlevel.
e
7
e8 Bonowetal. JACCVol.48,No.3,2006
ACC/AHAPracticeGuidelines August1,2006:e1–148
treatment of endocarditis, management of valve disease in Often, more than 1 of these factors is operative (5–7).
pregnancy, and treatment of patients with concomitant Aheartmurmurmayhavenopathologicalsignificanceor
coronary artery disease (CAD), as well as more specialized may be an important clue to the presence of valvular,
issues that pertain to specific valve lesions. The guidelines congenital,orotherstructuralabnormalitiesoftheheart(8).
focusprimarilyonvalvularheartdiseaseintheadult,witha Mostsystolicheartmurmursdonotsignifycardiacdisease,
separate section dealing with specific recommendations for andmanyarerelatedtophysiologicalincreasesinbloodflow
valve disorders in adolescents and young adults. The diag- velocity (9). In other instances, a heart murmur may be an
nosis and management of infants and young children with importantcluetothediagnosisofundetectedcardiacdisease
congenital valvular abnormalities are significantly different (e.g., valvular aortic stenosis [AS]) that may be important
from those of the adolescent or adult and are beyond the even when asymptomatic or that may define the reason for
scope of these guidelines. cardiac symptoms. In these situations, various noninvasive
This task force report overlaps with several previously orinvasivecardiactestsmaybenecessarytoestablishafirm
publishedACC/AHAguidelinesaboutcardiacimagingand diagnosis and form the basis for rational treatment of an
diagnostic testing, including the guidelines for the clinical underlyingdisorder.Echocardiographyisparticularlyuseful
use of cardiac radionuclide imaging (1), the clinical appli- in this regard, as discussed in the “ACC/AHA/ASE 2003
cation of echocardiography (2), exercise testing (3), and Guidelines for the Clinical Application of Echocardiogra-
percutaneous coronary intervention (4). Although these phy” (2). Diastolic murmurs virtually always represent
guidelines are not intended to include detailed information pathological conditions and require further cardiac evalua-
covered in previous guidelines on the use of imaging and tion, as do most continuous murmurs. Continuous “inno-
diagnostic testing, an essential component of this report is cent”murmursincludevenoushumsandmammarysouffles.
thediscussionofindicationsforthesetestsintheevaluation The traditional auscultation method of assessing cardiac
and treatment of patients with valvular heart disease. murmurshasbeenbasedontheirtiminginthecardiaccycle,
The committee emphasizes the fact that many factors configuration, location and radiation, pitch, intensity
ultimately determine the most appropriate treatment of (grades1through6),andduration(5–9).Theconfiguration
individualpatientswithvalvularheartdiseasewithinagiven of a murmur may be crescendo, decrescendo, crescendo-
community. These include the availability of diagnostic decrescendo (diamond-shaped), or plateau. The precise
equipmentandexpertdiagnosticians,theexpertiseofinter- times of onset and cessation of a murmur associated with
ventional cardiologists and surgeons, and notably, the cardiac pathology depend on the period of time in the
wishesofwell-informedpatients.Therefore,deviationfrom cardiac cycle in which a physiologically important pressure
theseguidelinesmaybeappropriateinsomecircumstances. differencebetween2chambersoccurs(5–9).Aclassification
These guidelines are written with the assumption that a of cardiac murmurs is listed in Table 1.
diagnostic test can be performed and interpreted with skill
2.1.2. Classification of Murmurs
levelsconsistentwithpreviouslyreportedACCtrainingand
competency statements and ACC/AHA guidelines, that Holosystolic (pansystolic) murmurs are generated when there
interventional cardiological and surgical procedures can be isflowbetweenchambersthathavewidelydifferentpressures
performedbyhighlytrainedpractitionerswithinacceptable throughoutsystole,suchastheleftventricleandeithertheleft
safetystandards,andthattheresourcesnecessarytoperform atriumorrightventricle.Withanabnormalregurgitantorifice,
thesediagnosticproceduresandprovidethiscarearereadily
the pressure gradient and regurgitant jet begin early in con-
available. This is not true in all geographic areas, which
tractionandlastuntilrelaxationisalmostcomplete.
furtherunderscoresthecommittee’spositionthatitsrecom-
Midsystolic (systolic ejection) murmurs, often crescendo-
mendations are guidelines and not rigid requirements.
decrescendo in configuration, occur when blood is ejected
acrosstheaorticorpulmonicoutflowtracts.Themurmursstart
2. GENERAL PRINCIPLES
shortlyafterS ,whentheventricularpressurerisessufficiently
1
2.1. Evaluation of the Patient With a Cardiac Murmur Table1. ClassificationofCardiacMurmurs
2.1.1. Introduction 1.Systolicmurmurs
a.Holosystolic(pansystolic)murmurs
Cardiac auscultation remains the most widely used method b.Midsystolic(systolicejection)murmurs
of screening for valvular heart disease. The production of c.Earlysystolicmurmurs
murmurs is due to 3 main factors: d.Midtolatesystolicmurmurs
• highbloodflowratethroughnormalorabnormalorifices 2.Diastolicmurmurs
a.Earlyhigh-pitcheddiastolicmurmurs
• forwardflowthroughanarrowedorirregularorificeinto b.Middiastolicmurmurs
a dilated vessel or chamber c.Presystolicmurmurs
• backward or regurgitant flow through an incompetent
3.Continuousmurmurs
valve
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