ESC 2025 2025 ESC/EACTS Guidelines for the management of valvular heart disease
European Society of Cardiology｜循環器 / 弁膜疾患｜102 ページ｜チャンク 1063｜推奨 295 件｜current
推奨表（自動抽出）
PDF の推奨表から機械的に抽出したものです。引用前に必ず該当ページの原文を確認してください。
| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.9 | IIa | B | quality to rule out significant CAD. | Table 3 New recommendations |
| p.9 | IIa | B | reference diameter ≥2.5 mm. | Table 3 New recommendations |
| p.9 | IIb | B | anatomy is suitable. | Table 3 New recommendations |
| p.9 | IIa | A | and LVEF ≥50%, as an alternative to close active surveillance, if the procedural risk is low. | Table 3 New recommendations |
| p.9 | IIb | B | TAVI may be considered for the treatment of severe BAV stenosis in patients at increased surgical risk, if the anatomy is suitable. | Table 3 New recommendations |
| p.9 | IIb | B | Minimally invasive MV surgery may be considered at experienced centres to reduce the length of stay and accelerate recovery. | Table 3 New recommendations |
| p.9 | IIa | B | medical therapy. | Table 3 New recommendations |
| p.9 | IIb | B | including rhythm control, when appropriate. | Table 3 New recommendations |
| p.9 | IIb | B | MV surgery may be considered in patients with moderate SMR undergoing CABG. | Table 3 New recommendations |
| p.9 | IIb | C | expertise in complex MV surgery and transcatheter interventions. | Table 3 New recommendations |
| p.10 | I | C | Careful evaluation of TR aetiology, stage of the disease (i.e. degree of TR severity, RV and LV dysfunction, and PH), patient operative risk, and likelihood of recovery by a multidisciplinary Heart Team is recommended in patients with severe TR prior to intervention. | |
| p.10 | I | C | MV surgery is recommended in patients with severe MR undergoing surgery for another valve. | |
| p.10 | I | B | gradient ≥40 mmHg or Vmax ≥4.0 m/s. | |
| p.10 | I | C | and LVEF <50% not attributable to other cardiac disease. | |
| p.10 | IIa | B | An MHV should be considered in patients with an estimated long life expectancy, if there are no contraindications for long-term OAC. | |
| p.10 | I | A | It is recommended that INR targets are based on the type and position of MHV, patient’s risk factors, and comorbidities. | |
| p.10 | I | A | Patient education is recommended to improve the quality of OAC. | |
| p.10 | I | A | Continuing VKA treatment is recommended in patients with an MHV for minor or minimally invasive interventions associated with no or minimal bleeding. | |
| p.10 | IIb | B | Interruption (3–4 days before surgery), and resumption of VKA without bridging, may be considered to reduce bleeding in patients with new-generation aortic MHV and no other thromboembolic risk factors undergoing major non-cardiac surgery or invasive procedures. | |
| p.10 | IIb | C | without clear indication for OAC. | |
| p.10 | III | B | DAPT is not recommended to prevent thrombosis after TAVI, unless there is a clear indication. | |
| p.10 | IIb | B | Low-dose ASA (75–100 mg/day) may be considered after surgical MV or TV repair in preference to OAC in patients without clear indication for OAC and at high bleeding risk. | |
| p.10 | I | B | OAC continuation is recommended in patients with a clear indication for OAC undergoing surgical BHV implantation. | |
| p.10 | IIb | B | DOAC continuation may be considered after surgical BHV implantation in patients with an indication for DOAC. | |
| p.10 | IIa | B | Continuation of OAC or antiplatelet therapy should be considered after surgical valve repair in patients with a clear indication for an antithrombotic therapy. | |
| p.10 | I | C | Reoperation is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. | |
| p.10 | I | C | TOE and/or 4D-CT are recommended in patients with suspected valve thrombosis to confirm the diagnosis. | |
| p.11 | I | C | Coronary angiography is recommended in the evaluation of severe SMR. I C Invasive coronary angiography is recommended in the evaluation of CAD in patients with severe ventricular SMR. | Table 4 Revised recommendations |
| p.11 | IIa | B | CHA2DS2-VASc score ≥2 undergoing valve surgery. | Table 4 Revised recommendations |
| p.11 | IIa | A | dysfunction, and other cardiovascular risk factors). | Table 4 Revised recommendations |
| p.11 | III | B | with AF and rheumatic MS with an MVA ≤2.0 cm2. | Table 4 Revised recommendations |
| p.11 | IIa | C | CCTA should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD. Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the | Table 4 Revised recommendations |
| p.11 | I | C | following: • History of cardiovascular disease • Suspected myocardial ischaemia • LV systolic dysfunction • In men >40 years of age and post-menopausal women • One or more cardiovascular risk factors. | Table 4 Revised recommendations |
| p.11 | IIa | C | PCI should be considered in patients with a primary indication to undergo TAVI and coronary artery diameter stenosis >70% in proximal segments. | Table 4 Revised recommendations |
| p.11 | IIa | C | indication to undergo transcatheter MV intervention and coronary artery diameter stenosis >70% in proximal segments. LAAO should be considered to reduce the thromboembolic risk in patients with AF and a Concomitant AF ablation should be considered in patients undergoing valve surgery, balancing the benefits of freedom from atrial arrhythmias and the risk factors for recurrence (LA dilatation, years in AF, age, renal | Table 4 Revised recommendations |
| p.11 | IIb | C | The use of DOACs is not recommended in patients AV repair may be considered in selected patients at experienced centres when durable results are expected. | Table 4 Revised recommendations |
| p.11 | IIb | C | Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF ≤55%, if surgery is at low risk. | Table 4 Revised recommendations |
| p.11 | I | B | Intervention is recommended in symptomatic patients with severe low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) AS with reduced LVEF (<50%), and evidence of flow (contractile) reserve. | Table 4 Revised recommendations |
| p.11 | I | B | CCTA is recommended before valve intervention in patients with moderate or lower (≤50%) pre-test likelihood of obstructive CAD. Invasive coronary angiography is recommended before valve intervention in patients with high and very high | Table 4 Revised recommendations |
| p.11 | I | C | (>50%) pre-test likelihood of obstructive CAD. PCI may be considered in patients with a primary indication to undergo transcatheter valve interventions | Table 4 Revised recommendations |
| p.11 | I | B | and coronary artery stenosis ≥70% in proximal Surgical closure of the LA appendage is recommended as an adjunct to OAC in patients with AF undergoing valve surgery to prevent cardioembolic stroke and systemic thromboembolism. | Table 4 Revised recommendations |
| p.11 | I | A | Concomitant surgical ablation is recommended in patients undergoing MV surgery with AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, according to an experienced team of electrophysiologists and arrhythmia surgeons. | Table 4 Revised recommendations |
| p.11 | IIa | B | Concomitant surgical ablation should be considered in patients undergoing non-MV surgery with AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, according to an experienced team of electrophysiologists and arrhythmia surgeons. | Table 4 Revised recommendations |
| p.11 | IIa | B | AV repair should be considered in selected patients with severe AR at experienced centres, when durable results are expected. | Table 4 Revised recommendations |
| p.11 | IIb | B | AV surgery may be considered in asymptomatic patients with severe AR and LVESDi >22 mm/m2 or LVESVi >45 mL/m2 [especially in patients with small body size (BSA <1.68 m2)], or resting LVEF ≤55%, if surgical risk is low. | Table 4 Revised recommendations |
| p.11 | I | B | Intervention is recommended in symptomatic patients with low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) AS with reduced LVEF (<50%) after careful confirmation that AS is severe. | Table 4 Revised recommendations |
| p.12 | I | A | TAVI is recommended in patients ≥70 years of age with tricuspid AV stenosis, if the anatomy is suitable. | |
| p.12 | I | B | the surgical risk is low. | |
| p.12 | IIa | C | Intervention should be considered in symptomatic patients with low-flow, low-gradient (<40 mmHg) AS with normal LVEF after careful confirmation that the AS is severe. | |
| p.12 | IIa | B | Intervention should be considered in asymptomatic patients with severe AS and LV dysfunction (LVEF <55%) without another cause. Intervention should be considered in asymptomatic patients with LVEF >55% and a normal exercise test if | |
| p.12 | IIa | B | the procedural risk is low and one of the following parameters is present: • Very severe AS (mean gradient ≥60 mmHg or Vmax >5 m/s). • Severe valve calcification (ideally assessed by CCT) and Vmax progression ≥0.3 m/s/year. • Markedly elevated BNP levels (more than three times age- and sex-corrected normal range) confirmed by repeated measurements and without other | |
| p.12 | I | C | explanation. The choice between surgical and transcatheter intervention must be based upon careful evaluation of clinical, anatomical, and procedural factors by the Heart Team, weighing the risks and benefits of each approach for an individual patient. The Heart Team recommendation should be discussed with the patient who can then make an informed treatment choice. | |
| p.12 | I | A | TAVI is recommended in older patients (≥75 years), or in those who are high risk (STS-PROM/EuroSCORE II >8%) or unsuitable for surgery. | |
| p.12 | I | B | SAVR is recommended in younger patients who are low risk for surgery (<75 years and STS-PROM/ EuroSCORE II <4%), or in patients who are operable and unsuitable for transfemoral TAVI. | |
| p.12 | I | B | SAVR or TAVI are recommended for remaining patients according to individual clinical, anatomical, and procedural characteristics. | |
| p.12 | IIb | C | Non-transfemoral TAVI may be considered in patients who are inoperable and unsuitable for transfemoral TAVI. | |
| p.12 | IIa | B | Surgery should be considered in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to MR or PH (SPAP at rest >50 mmHg). | |
| p.12 | IIa | B | Surgical MV repair should be considered in low-risk asymptomatic patients with LVEF >60%, LVESD <40 mm, and significant LA dilatation (volume index ≥60 mL/m2 or diameter ≥55 mm) when performed in a Heart Valve Centre and a durable repair is likely. | |
| p.12 | IIa | B | Intervention should be considered in symptomatic patients with low-flow (SVi ≤35 mL/m2), low-gradient (<40 mmHg) AS with normal LVEF (≥50%) after careful confirmation that AS is severe. Intervention should be considered in asymptomatic patients with severe AS and LVEF ≥50%, if the procedural risk is low and one of the following | |
| p.12 | IIa | B | parameters is present: • Very severe AS (mean gradient ≥60 mmHg or Vmax >5.0 m/s). • Severe valve calcification (ideally assessed by CCT) and Vmax progression ≥0.3 m/s/year. • Markedly elevated BNP/NT-proBNP levels (more than three times age- and sex-corrected normal range, confirmed on repeated measurement without other explanation). • LVEF <55% without another cause. | |
| p.12 | I | C | It is recommended that the mode of intervention is based on Heart Team assessment of individual clinical, anatomical, and procedural characteristics, incorporating lifetime management considerations and estimated life expectancy. | |
| p.12 | I | B | SAVR is recommended in patients <70 years of age, if SAVR or TAVI are recommended for all remaining candidates for an aortic BHV according to Heart Team assessment.1–4 | |
| p.12 | IIa | B | Non-transfemoral TAVI should be considered in patients who are unsuitable for surgery and transfemoral access. | |
| p.12 | IIa | B | MV surgery should be considered in asymptomatic patients with severe PMR without LV dysfunction (LVESD <40 mm, LVESDi <20 mm/m2, and LVEF >60%) in the presence of PH (SPAP at rest >50 mmHg), or AF secondary to MR. | |
| p.13 | IIa | B | high surgical risk according to the Heart Team. | |
| p.13 | IIb | C | considered in symptomatic patients with chronic severe ventricular SMR and non-complex CAD. | |
| p.13 | I | B | secondary TR undergoing left-sided valve surgery. | |
| p.13 | IIa | C | primary TR undergoing left-sided valve surgery. | |
| p.13 | IIb | C | indication for long-term OAC. | |
| p.13 | I | B | OAC using a VKA is recommended lifelong for all patients with an MHV prosthesis. | |
| p.13 | IIb | B | TEER may be considered in symptomatic patients who fulfil the echocardiographic criteria of eligibility, are judged inoperable or at high surgical risk by the Heart Team, and for whom the procedure is not considered futile. | |
| p.13 | IIa | C | In symptomatic patients who are judged not appropriate for surgery by the Heart Team on the basis of their individual characteristics, PCI (and/or TAVI) possibly followed by TEER (in case of persisting severe SMR) should be considered. TEER should be considered in selected symptomatic patients not eligible for surgery and fulfilling criteria suggesting an increased chance of responding to the | |
| p.13 | IIb | C | In high-risk symptomatic patients not eligible for surgery and not fulfilling the criteria suggesting an increased chance of responding to TEER, the Heart Team may consider in selected cases a TEER procedure or other transcatheter valve therapy if applicable, after careful evaluation for ventricular assist device or heart | |
| p.13 | IIb | C | transplant. Valve surgery may be considered in symptomatic patients judged appropriate for surgery by the Heart Team. Surgery is recommended in patients with severe | |
| p.13 | IIa | B | Surgery should be considered in patients with moderate Surgery should be considered in patients with mild or moderate secondary TR with a dilated annulus (≥40 mm or >21 mm/m2 by 2D echocardiography) undergoing left-sided valve surgery. | |
| p.13 | IIb | C | Section 11.4 Transcatheter treatment of symptomatic secondary severe TR may be considered in inoperable patients at a Heart Valve Centre with expertise in the treatment of TV disease. | |
| p.13 | IIb | C | Prosthetic valve selection—Section 14.1 A mechanical prosthesis may be considered in patients already on long-term anticoagulation due to the high risk for thromboembolism. | |
| p.13 | I | A | with severe PMR who are anatomically suitable and at PCI followed by TEER after re-evaluation of MR may be TEER is recommended to reduce HF hospitalizations and improve quality of life in haemodynamically stable, symptomatic patients with impaired LVEF (<50%) and persistent severe ventricular SMR, despite optimized GDMT and CRT (if indicated), fulfilling specific clinical and echocardiographic criteria. | |
| p.13 | IIb | B | TEER may be considered for symptom improvement in selected symptomatic patients with severe ventricular SMR not fulfilling the specific clinical and echocardiographic criteria, after careful evaluation of LVAD or HTx. | |
| p.13 | IIb | C | MV surgery may be considered in symptomatic patients with severe ventricular SMR without advanced HF who are not suitable for TEER. | |
| p.13 | IIa | B | Concomitant TV repair should be considered in patients with moderate primary or secondary TR, to avoid progression of TR and RV remodelling. | |
| p.13 | IIb | B | Concomitant TV repair may be considered in selected patients with mild secondary TR and tricuspid annulus dilatation (≥40 mm or >21 mm/m2) to avoid progression of TR and RV remodelling. | |
| p.13 | IIa | A | Transcatheter TV treatment should be considered to improve quality of life and RV remodelling in high-risk patients, with symptomatic severe TR despite optimal medical therapy, in the absence of severe RV dysfunction or pre-capillary PH. An MHV may be considered in patients with a clear | |
| p.13 | I | A | Lifelong OAC with a VKA is recommended for all patients with MHVs to prevent thromboembolic complications. | |
| p.14 | IIa | C | despite an adequate INR. | |
| p.14 | III | A | DOACs are not recommended in patients with an MHV prosthesis. III B DOACs and/or DAPT are not recommended to prevent thrombosis in patients with an MHV. | |
| p.14 | I | C | the VKA on the first post-operative day. | |
| p.14 | I | B | other indications for OAC. | |
| p.14 | IIa | B | during the first 3 months after surgical MV or TV repair. | |
| p.14 | III | A | patients without baseline indication. | |
| p.14 | IIa | C | patient risk status, leak morphology, and local expertise. | |
| p.14 | I | B | For patients with a VKA, INR self-management is recommended provided appropriate training and quality control are performed. In patients with MHVs, it is recommended to (re)initiate | |
| p.14 | I | C | indication for post-operative therapeutic bridging, it is recommended to start either UFH or LMWH 12–24 h after surgery. | |
| p.14 | IIb | C | The addition of low-dose ASA (75–100 mg/day) to VKA may be considered in selected patients with MHVs in case of concomitant atherosclerotic disease and low risk of bleeding. The addition of low-dose ASA (75–100 mg/day) to VKA should be considered after thromboembolism procedures—Section 14.3 | |
| p.14 | I | C | It is recommended that VKAs are timely discontinued Therapeutic doses of either UFH or subcutaneous Bridging of OAC, when interruption is needed, is recommended in patients with any of the following indications: • MHV • AF with significant MS • AF with CHA2DS2-VASc score ≥3 for women or 2 for men • Acute thrombotic event within the previous 4 weeks • High acute thromboembolic risk. | |
| p.14 | I | A | Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC. OAC is recommended lifelong for TAVI patients who OAC with VKA should be considered during the first Routine use of OAC is not recommended after TAVI in Decision on transcatheter or surgical closure of clinically significant PVLs should be considered based on | |
| p.14 | I | A | INR self-monitoring and self-management are recommended over standard monitoring in selected, trained patients to improve efficacy. | |
| p.14 | IIa | B | The addition of low-dose ASA (75–100 mg/day) to VKA should be considered in selected patients with MHVs in case of concomitant symptomatic atherosclerotic disease, considering the individual bleeding risk profile. | |
| p.14 | IIa | C | Either an increase in INR target or the addition of low-dose ASA (75–100 mg/day) should be considered in patients with MHVs who develop a major thromboembolic complication despite documented adequate INR. | |
| p.14 | IIa | B | before major elective non-cardiac surgery, aiming for an INR <1.5, and to resume VKA treatment within 24 h after surgery, or as soon as considered safe. be considered in patients with an MHV and thromboembolic risk factors undergoing major non-cardiac surgery. | |
| p.14 | I | A | Low-dose ASA (75–100 mg/day) is recommended for 12 months after TAVI in patients without indication for OAC. | |
| p.14 | IIa | C | Long-term (after the first 12 months) low-dose ASA (75–100 mg/day) should be considered after TAVI in patients without clear indication for OAC. | |
| p.14 | I | C | It is recommended that the decision between transcatheter or surgical closure of clinically significant PVLs is based on Heart Team evaluation, including patient risk, leak morphology, and local expertise. | |
| p.15 | I | C | attributable to valve thrombosis. | |
| p.15 | IIb | B | patients at high risk for surgical reintervention. | |
| p.15 | I | B | before considering reintervention. | |
| p.15 | IIa | B | Transcatheter closure should be considered for suitable PVLs with clinically significant regurgitation and/or haemolysis in patients at high or prohibitive surgical risk. | |
| p.15 | I | C | Reoperation is recommended in symptomatic patients with a significant increase in transprosthetic gradient (after exclusion of valve thrombosis) or severe regurgitation. | |
| p.15 | IIa | B | Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team depending on anatomical considerations, features of the prosthesis, and in patients who are at high operative risk or inoperable. Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in selected | |
| p.15 | I | B | Urgent or emergency valve replacement is recommended for obstructive thrombosis in critically ill patients without serious comorbidity. | |
| p.15 | IIa | B | activator 10 mg bolus + 90 mg in 90 min with UFH or streptokinase 1 500 000 U in 60 min without UFH) should be considered when surgery is not available or is very high risk, or for thrombosis of right-sided prostheses. | |
| p.15 | I | C | Anticoagulation using a VKA and/or UFH is recommended in BHV thrombosis before considering reintervention. | |
| p.15 | IIa | B | Transcatheter transfemoral valve-in-valve implantation in the aortic position should be considered in patients with significant valve dysfunction who are at intermediate or high surgical risk, and have suitable anatomical and prosthesis features, as assessed by the Heart Team. | |
| p.15 | IIa | B | Transcatheter transvenous mitral or tricuspid valve-in-valve implantation should be considered in patients with significant valve dysfunction at intermediate or high surgical risk, if the anatomy is suitable. Heart Team evaluation is recommended in patients with acute HF (NYHA class III or IV) due to obstructive MHV thrombosis to determine appropriate | |
| p.22 | I | B | Diagnosis of coronary artery disease CCTA is recommended before valve intervention in patients with moderate or lower (≤50%) pre-test likelihood of obstructive CAD.122–124 | Recommendation Table 1 — Recommendations for the management of chronic coronary syndrome in patients with valvular heart disease (see also Supplementary data online, Evidence Table 1) |
| p.22 | I | C | Invasive coronary angiography is recommended before valve intervention in patients with high and very high (>50%) pre-test likelihood of obstructive CAD. | Recommendation Table 1 — Recommendations for the management of chronic coronary syndrome in patients with valvular heart disease (see also Supplementary data online, Evidence Table 1) |
| p.22 | I | C | Invasive coronary angiography is recommended in the evaluation of CAD in patients with severe ventricular SMR. | Recommendation Table 1 — Recommendations for the management of chronic coronary syndrome in patients with valvular heart disease (see also Supplementary data online, Evidence Table 1) |
| p.22 | IIa | B | Omission of invasive coronary angiography should be considered in TAVI candidates, if procedural planning CT angiography is of sufficient quality to rule out significant CAD.125–129 | Recommendation Table 1 — Recommendations for the management of chronic coronary syndrome in patients with valvular heart disease (see also Supplementary data online, Evidence Table 1) |
| p.23 | I | C | Indications for myocardial revascularization CABG is recommended in patients with a primary indication for valve surgery and coronary artery stenosis ≥70%.c | |
| p.23 | IIa | C | CABG should be considered in patients with a primary indication for valve surgery and coronary artery stenosis ≥50%–70%. | |
| p.23 | IIa | B | PCI should be considered in patients with a primary indication to undergo TAVI and ≥90% coronary artery stenosis in segments with a reference diameter ≥2.5 mm.134 | |
| p.23 | IIb | B | indication to undergo transcatheter valve interventions and coronary artery stenosis ≥70% in proximal segments of main vessels.135–137 | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.23 | I | A | © ESC/EACTS 2025 Anticoagulation DOACs are recommended for stroke prevention in preference to VKAs in patients with AF and AS, AR, or MR who are eligible for OAC.156–159,164 | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.23 | III | B | The use of DOACs is not recommended in patients with AF and rheumatic MS with an MVA ≤2.0 cm2.165 Surgical interventions | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.23 | I | A | Concomitant surgical ablation is recommended in patients undergoing MV surgery with AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, according to an experienced team of electrophysiologists and arrhythmia surgeons.166–173 | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.23 | I | B | Surgical closure of the LA appendage is recommended as an adjunct to OAC in patients with AF undergoing valve surgery to prevent cardioembolic stroke and systemic thromboembolism.160–162 | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.23 | IIa | B | Concomitant surgical ablation should be considered in patients undergoing non-MV surgery with AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, according to an experienced team of electrophysiologists and arrhythmia surgeons.167,169,174,175 | Recommendation Table 2 — Recommendations for the management of atrial fibrillation in patients with native valvular heart disease (see also Supplementary data online, Evidence Tables 2 and 3) |
| p.28 | I | B | AV surgery is recommended in symptomatic patients with severe AR regardless of LV function.224–228 | Recommendation Table 3 — Recommendations on indications for intervention in severe aortic regurgitation (see also Supplementary data online, Evidence Tables 4–8) |
| p.28 | I | B | Severe aortic regurgitation AV surgery is recommended in asymptomatic patients with severe AR and LVESD >50 mm or LVESDi >25 mm/m2 [especially in patients with small body size (BSA <1.68 m2)] or resting LVEF ≤50%.226,228,231,233,234 | Recommendation Table 3 — Recommendations on indications for intervention in severe aortic regurgitation (see also Supplementary data online, Evidence Tables 4–8) |
| p.28 | I | C | AV surgery is recommended in symptomatic and asymptomatic patients with severe AR undergoing CABG or surgery of the ascending aorta. | Recommendation Table 3 — Recommendations on indications for intervention in severe aortic regurgitation (see also Supplementary data online, Evidence Tables 4–8) |
| p.28 | IIa | B | AV repair should be considered in selected patients with severe AR at experienced centres, when durable results are expected.220,245,246,259 AV surgery may be considered in asymptomatic patients | Recommendation Table 3 — Recommendations on indications for intervention in severe aortic regurgitation (see also Supplementary data online, Evidence Tables 4–8) |
| p.28 | IIb | B | with severe AR and LVESDi >22 mm/m2,226,228,231–234 or LVESVic >45 mL/m2 [especially in patients with small body size (BSA <1.68 m2)],235–241 or resting LVEF ≤55%, if the surgical risk is low. | Recommendation Table 3 — Recommendations on indications for intervention in severe aortic regurgitation (see also Supplementary data online, Evidence Tables 4–8) |
| p.28 | IIb | B | TAVI may be considered for the treatment of severe AR in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable.264,265,268,269 | |
| p.28 | I | B | Concomitant surgery of the ascending aorta Valve-sparing aortic root replacement is recommended in young patients with aortic root dilatation at experienced centres, when durable results are expected.247,250–253,255 | |
| p.28 | IIa | C | When AV surgery is indicated and the predicted surgical risk is low, replacement of the aortic root or ascending aorta should be considered if the maximal diameter is ≥45 mm.d 8 Aortic stenosis | |
| p.36 | I | B | AVA ≤1.0 cm2 (or ≤0.6 cm2/m2 BSA)].388,471–474 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | B | (<50%) after careful confirmation that AS is severe.342,345,346,348,475 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIa | B | LVEF (≥50%) after careful confirmation that AS is severe.c 293,348,349,476–481 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | B | Intervention is recommended in asymptomatic patients with severe AS and LVEF <50% without another cause.14,354–359 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIa | A | Intervention should be considered in asymptomatic patients (confirmed by a normal exercise test, if feasible) with severe, high-gradient AS and LVEF ≥50% as an alternative to close active surveillance, if the procedural risk is low.360–363,367,368 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIa | C | Intervention should be considered in asymptomatic patients with severe AS and a sustained fall in BP (>20 mmHg) during exercise testing. | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | C | It is recommended that AV interventions are performed in Heart Valve Centres that report their local expertise and outcome data, have on-site interventional cardiology and cardiac surgical programmes, and a structured collaborative Heart Team. | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | C | It is recommended that the mode of intervention is based on Heart Team assessment of individual clinical, anatomical, and procedural characteristics, incorporating lifetime management considerations and estimated life expectancy. | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | A | TAVI is recommended in patients ≥70 years of age with tricuspid AV stenosis, if the anatomy is suitable.d 1–4,389–397,465,485,486 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | B | SAVR is recommended in patients <70 years of age, if the surgical risk is low.e 413,429,487 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | I | B | SAVR or TAVI are recommended for all remaining candidates for an aortic BHV according to Heart Team assessment.2,4,396,397,429,488–490 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIa | B | Non-transfemoral TAVI should be considered in patients who are unsuitable for surgery and transfemoral access.417–423,491–498 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIb | B | TAVI may be considered for the treatment of severe BAV stenosis in patients at increased surgical risk, if the anatomy is suitable.430–432,434,499–502 | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.36 | IIb | C | Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients, and (if feasible) in those with severe AS who require urgent high-risk NCS. | Recommendation Table 4 — Recommendations on indications for intervention in symptomatic and asymptomatic severe aortic stenosis, and recommended mode of intervention (see also Supplementary data online, Evidence Tables 9–13) |
| p.37 | I | C | SAVR is recommended in symptomatic and asymptomatic patients with severe AS undergoing CABG or surgical intervention on the ascending aorta. | Recommendation Table 5 — Recommendations on indications for concomitant aortic valve replacement at the time of coronary artery bypass grafting or ascending aorta surgery |
| p.37 | IIa | C | SAVR should be considered in symptomatic and asymptomatic patients with moderate ASc undergoing CABG or surgical intervention on the ascending aorta. | Recommendation Table 5 — Recommendations on indications for concomitant aortic valve replacement at the time of coronary artery bypass grafting or ascending aorta surgery |
| p.40 | I | B | MV repair is the recommended surgical technique to treat patients with severe PMR when the result is expected to be durable.26,532,533,559,560 | Recommendation Table 6 — Recommendations on indications for intervention in severe primary mitral regurgitation (see also Supplementary data online, Evidence Tables 14–16) |
| p.40 | I | B | MV surgery is recommended in symptomatic patients with severe PMR considered operable by the Heart Team.26,532,533,561 | Recommendation Table 6 — Recommendations on indications for intervention in severe primary mitral regurgitation (see also Supplementary data online, Evidence Tables 14–16) |
| p.40 | I | B | MV surgery is recommended in asymptomatic patients with severe PMR and LV dysfunction (LVESD ≥40 mm or LVESDi ≥20 mm/m2 or LVEF ≤60%).522,544,545 | Recommendation Table 6 — Recommendations on indications for intervention in severe primary mitral regurgitation (see also Supplementary data online, Evidence Tables 14–16) |
| p.41 | I | B | Surgical MV repair is recommended in low-risk asymptomatic patients with severe PMR without LV dysfunction (LVESD <40 mm, LVESDi <20 mm/m2, and LVEF >60%) when a durable result is likely, if at least three of the following criteria are fulfilled:517,547,562–564 • AF • SPAP at rest >50 mmHg • LA dilatation (LAVI ≥60 mL/m2 or LA diameter ≥55 mm) • Concomitant secondary TR ≥ moderate. MV surgery should be considered in asymptomatic | |
| p.41 | IIa | B | patients with severe PMR without LV dysfunction (LVESD <40 mm, LVESDi <20 mm/m2, and LVEF >60%) in the presence of PH (SPAP at rest >50 mmHg), or AF secondary to MR.517,518,562,565 Surgical MV repair should be considered in low-risk asymptomatic patients with severe PMR without LV dysfunction (LVESD <40 mm, LVESDi <20 mm/m2, and LVEF >60%) in the presence of significant LA dilatation (LAVI ≥60 mL/m2 or LA diameter ≥55 mm), when performed in a Heart Valve Centre and a durable repair is likely.517,565 | |
| p.41 | IIa | B | TEER should be considered in symptomatic patients with severe PMR who are anatomically suitable and at high surgical risk according to the Heart Team.538,540,566 | |
| p.41 | IIb | B | Minimally invasive MV surgery may be considered at experienced centres to reduce the length of stay and accelerate recovery.557,567 | |
| p.45 | I | B | ventricular SMR undergoing CABG.640 | |
| p.45 | IIb | B | moderate SMR undergoing CABG.622–624,641,642 | |
| p.45 | IIa | B | Severe atrial secondary mitral regurgitation MV surgery, surgical AF ablation, if indicated, and LAAO should be considered in symptomatic patients with severe atrial SMR under optimal medical therapy.627–630,636,637 | Recommendation Table 7 — Recommendations on indications for intervention in secondary mitral regurgitation (see also Supplementary data online, Evidence Tables 17–20) |
| p.45 | IIb | B | TEER may be considered in symptomatic patients with severe atrial SMR not eligible for surgery after optimization of medical therapy including rhythm control, when appropriate.588,590,638,639 | Recommendation Table 7 — Recommendations on indications for intervention in secondary mitral regurgitation (see also Supplementary data online, Evidence Tables 17–20) |
| p.45 | IIb | C | coronary artery disease MV surgery is recommended in patients with severe MV surgery may be considered in patients with PCI followed by TEER after re-evaluation of MR may be considered in symptomatic patients with chronic severe ventricular SMR and non-complex CAD.150 concomitant coronary artery disease | |
| p.45 | I | A | TEER is recommended to reduce HF hospitalizations and improve quality of life in haemodynamically stable, symptomatic patients with impaired LVEF (<50%) and persistent severe ventricular SMR, despite optimized GDMT and CRT (if indicated), fulfilling specific clinical and echocardiographic criteria.c 583,584,606,608,643 | |
| p.45 | IIb | B | TEER may be considered for symptom improvement in selected symptomatic patients with severe ventricular SMR not fulfilling the specific clinical and echocardiographic criteria,c after careful evaluation of LVAD or HTx.203,608–610 | |
| p.45 | IIb | C | MV surgery may be considered in symptomatic patients with severe ventricular SMR without advanced HF who are not suitable for TEER.617 10 Mitral stenosis | |
| p.48 | I | B | 651–653,662,665 | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.48 | I | C | with a contraindication or at high risk for surgery. | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.48 | I | C | patients who are not suitable for PMC. | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.48 | IIa | C | PMC is recommended in symptomatic patients in the absence of unfavourable characteristics for PMC.c PMC is recommended in any symptomatic patients MV surgery is recommended in symptomatic PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy but no unfavourable clinical characteristics for PMC.c PMC should be considered in asymptomatic patients | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.48 | IIa | C | without unfavourable clinical and anatomical characteristics for PMC, and: • High thromboembolic risk (history of systemic embolism, dense spontaneous contrast in the LA, new-onset or paroxysmal AF), and/or • High risk of haemodynamic decompensation (SPAP >50 mmHg at rest, need for major NCS, pregnant or desire for pregnancy). | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.48 | IIb | C | TMVI may be considered in symptomatic patients with extensive MAC and severe MV dysfunction at experienced Heart Valve Centres with expertise in complex MV surgery and transcatheter interventions.542,680,681 | Recommendation Table 8 — Recommendations on indications for percutaneous mitral commissurotomy, mitral valve surgery, and transcatheter intervention in clinically severe rheumatic and degenerative mitral stenosis (see also Supplementary data online, Evidence Table 21) |
| p.53 | I | C | Careful evaluation of TR aetiology, stage of the disease (i.e. degree of TR severity, RV and LV dysfunction, and PH), patient operative risk, and likelihood of recovery by a multidisciplinary Heart Team is recommended in patients with severe TR prior to intervention.691,742 | Recommendation Table 9 — Recommendations on indications for intervention in tricuspid regurgitation (see also Supplementary data online, Evidence Tables 22 and 23) |
| p.53 | I | B | heart disease requiring surgery Concomitant TV surgeryc is recommended in patients with severe primary or secondary TR.725,731,743,744 | |
| p.53 | IIa | B | Concomitant TV repair should be considered in patients with moderate primary or secondary TR, to avoid progression of TR and RV remodelling.723,724,726,731 | |
| p.53 | IIb | B | Concomitant TV repair may be considered in selected patients with mild secondary TR and tricuspid annulus dilatation (≥40 mm or >21 mm/m2), to avoid progression of TR and RV remodelling.723–726,731,743 | |
| p.53 | I | C | TV surgeryc is recommended in symptomatic patients with severe primary TR without severe RV dysfunction or severe PH. | |
| p.53 | IIa | C | TV surgeryc should be considered in asymptomatic patients with severe primary TR who have RV dilatation/RV function deterioration, but without severe LV/RV dysfunction or severe PH. | |
| p.53 | IIa | B | TV surgeryc should be considered in patients with severe secondary TR who are symptomatic or have RV dilatation/RV function deterioration, but without severe LV/RV dysfunction or PH.685,720,745–747 | |
| p.53 | IIa | A | Transcatheter TV treatment should be considered to improve quality of life and RV remodelling in high-risk patients with symptomatic severe TR despite optimal medical therapy in the absence of severe RV dysfunction or pre-capillary PH.713,733,735,738,748–751 12 Tricuspid stenosis | |
| p.54 | I | C | Surgeryc is recommended in symptomatic patients with severe TS.d | Recommendation Table 10 — Recommendations on indications for intervention in tricuspid stenosis |
| p.54 | I | C | Surgeryc is recommended in patients with severe TS undergoing left-sided valve intervention.e | Recommendation Table 10 — Recommendations on indications for intervention in tricuspid stenosis |
| p.56 | I | C | undergoing surgery for another valve. | Recommendation Table 11 — Recommendations on indications for surgery of concomitant left-sided valvular heart diseasea |
| p.56 | IIa | C | moderate ASd undergoing surgery for another valve. | Recommendation Table 11 — Recommendations on indications for surgery of concomitant left-sided valvular heart diseasea |
| p.56 | I | C | AV surgery is recommended in patients with severe AR undergoing surgery for another valve. | Recommendation Table 11 — Recommendations on indications for surgery of concomitant left-sided valvular heart diseasea |
| p.56 | I | C | MV surgery is recommended in patients with severe MR undergoing surgery for another valve. | Recommendation Table 11 — Recommendations on indications for surgery of concomitant left-sided valvular heart diseasea |
| p.56 | I | B | Intervention is recommended in symptomatic patients with mixed moderate AV stenosisc and moderate regurgitation, and a mean gradient ≥40 mmHg or Vmax ≥4.0 m/s.790–793 | Recommendation Table 12 — Recommendations on indications for intervention in patients with mixed moderate aortic stenosis and moderate aortic regurgitation (see also Supplementary data online, Evidence Table 24) |
| p.56 | I | C | Intervention is recommended in asymptomatic patients with mixed moderate AV stenosisc and moderate regurgitation with Vmax ≥4.0 m/s, and LVEF <50% not attributable to other cardiac disease.791 | Recommendation Table 12 — Recommendations on indications for intervention in patients with mixed moderate aortic stenosis and moderate aortic regurgitation (see also Supplementary data online, Evidence Table 24) |
| p.57 | IIa | C | pre-existing MHV in another position. | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | IIb | C | indication for long-term OAC. | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | I | C | A BHV is recommended according to the desire of the informed patient. | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | IIa | C | contemplating pregnancy. | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | I | C | Mechanical heart valve An MHV is recommended according to the desire of the informed patient and if there is no contraindication to long-term anticoagulation. | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | IIa | B | An MHV should be considered in patients with an estimated long life expectancy,c if there are no contraindications for long-term OAC.801,807–811 | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | IIa | C | An MHV should be considered in patients aged <60 years for prostheses in the aortic position and aged <65 years for prostheses in the mitral position.801,807–811 An MHV should be considered in patients with a An MHV may be considered in patients with a clear | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | I | C | Biological heart valve A BHV is recommended when an adequate quality of anticoagulation with VKA is unlikely, in patients at high bleeding risk, or with estimated short life expectancy.c | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.57 | IIa | C | A BHV should be considered in patients aged >65 years for prostheses in the aortic position or aged >70 years for prostheses in the mitral position. A BHV should be considered in women | Recommendation Table 13 — Recommendations for prosthetic valve selection |
| p.59 | I | B | considered safe.815,816,832–834 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | I | A | Lifelong OAC with a VKA is recommended for all patients with MHVs to prevent thromboembolic complications.821–823,835–838 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | I | A | efficacy.827,828 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | I | A | It is recommended that INR targets are based on the type and position of the MHV, patient risk factors, and comorbidities.c 818,819,835–838 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | I | A | Patient education is recommended to improve the quality of OAC.827–830 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | IIa | B | symptomatic atherosclerotic disease considering the individual bleeding risk profile.818 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | IIa | C | develop a major thromboembolic complication despite documented adequate INR.818 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.59 | III | A | DOACs and/or DAPT are not recommended to prevent thrombosis in patients with an MHV.821–824 | Recommendation Table 14 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve |
| p.60 | I | A | bleeding.851–856 | Recommendation Table 15 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve undergoing elective non-cardiac surgery or invasive procedures |
| p.60 | I | B | treatment within 24 h after surgery, or as soon as considered safe.816,857,858 | Recommendation Table 15 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve undergoing elective non-cardiac surgery or invasive procedures |
| p.60 | IIa | B | undergoing major NCS.816,857,858 | Recommendation Table 15 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve undergoing elective non-cardiac surgery or invasive procedures |
| p.60 | IIb | B | new-generation aortic MHVs and no other thromboembolic risk factorse undergoing major NCS or invasive procedures.816,857,858,861–864 | Recommendation Table 15 — Recommendations for the management of antithrombotic therapy in patients with a mechanical heart valve undergoing elective non-cardiac surgery or invasive procedures |
| p.62 | III | B | after TAVI, unless there is a clear indication.881 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | III | A | in patients without baseline indication.869,880 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | B | anticoagulation Low-dose ASA (75–100 mg/day) or OAC using a VKA should be considered for the first 3 months after surgical implantation of an aortic BHV in patients without clear indication for OAC.865,866 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | B | A VKA should be considered for the first 3 months after surgical implantation of a mitral or tricuspid BHV in patients without clear indication for OAC.867,868 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIb | C | Lifelong low-dose ASA (75–100 mg/day) may be considered 3 months after surgical implantation of an aortic or mitral BHV in patients without clear indication for OAC. | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | I | A | oral anticoagulation Low-dose ASA (75–100 mg/day) is recommended for 12 months after TAVI in patients without indication for OAC.869,880–883 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | C | Long-term (after the first 12 months) low-dose ASA (75–100 mg/day) should be considered after TAVI in patients without clear indication for OAC. DAPT is not recommended to prevent thrombosis Routine use of OAC is not recommended after TAVI | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | B | OAC, with either VKAs or DOACs, should be considered during the first 3 months after surgical MV or TV repair.884–888 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | C | Low-dose ASA (75–100 mg/day) should be considered for the first 3 months after surgical AV repair in patients without indication for OAC. | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIb | B | Low-dose ASA (75–100 mg/day) may be considered after surgical MV or TV repair in preference to OAC in patients without clear indication for OAC and at high bleeding risk.884–888 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | I | B | anticoagulation OAC continuation is recommended in patients with a clear indication for OAC undergoing surgical BHV implantation.877,889,890 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIa | B | DOACs should be considered over VKAs after 3 months following surgical implantation of a BHV in patients with AF.872–874,876,891 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.62 | IIb | B | DOAC continuation may be considered after surgical BHV implantation in patients with an indication for DOAC. 877,889,890 | Recommendation Table 16 — Recommendations for the management of antithrombotic therapy in patients with a biological heart valve or valve repair |
| p.63 | I | B | other indications for OAC.879,892–894 | |
| p.63 | IIa | B | anticoagulation OAC is recommended for TAVI patients who have Continuation of OAC or antiplatelet therapy should be considered after surgical valve repair in patients with a clear indication for an antithrombotic therapy.890 | |
| p.66 | I | C | It is recommended that the decision between transcatheter or surgical closure of clinically significant PVLs is based on Heart Team evaluation, including patient risk, leak morphology, and local expertise. | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | C | Reoperation is recommended if a PVL is related to endocarditis, or causes haemolysis requiring repeated blood transfusion or leading to HF symptoms. | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | IIa | B | Transcatheter closure should be considered for suitable PVLs with clinically significant regurgitation and/or haemolysis.940 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | C | Reoperation is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | C | Reintervention is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | IIa | B | Transcatheter transvenous mitral or tricuspid valve-in-valve implantation should be considered in patients with significant valve dysfunction at intermediate or high surgical risk, if the anatomy is suitable.569,570,681,942–944 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | IIa | C | Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction, if surgical risk is low. | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | C | TOE and/or 4D-CT are recommended in patients with suspected valve thrombosis to confirm the diagnosis.914,918,923,925,945–948 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | B | Heart Team evaluation is recommended in patients with acute HF (NYHA class III or IV) due to obstructive MHV thrombosis to determine appropriate management (repeat valve replacement or low-dose slow infusion fibrinolysis).923,926–929,931,949–954 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | IIa | C | Surgery should be considered for large (>10 mm) prosthetic thrombus complicated by embolism.913,932,933 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | I | B | OAC using VKA is recommended in BHV thrombosis before considering reintervention.867,934–937,955,956 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.66 | IIa | B | OAC should be considered in patients with leaflet thickening and reduced leaflet motion leading to elevated gradients at least until resolution.918,920–922 | Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25) |
| p.73 | I | B | CCTA is recommended before valve intervention in patients with moderate or lower (≤50%) pre-test likelihood of obstructive CAD. | |
| p.73 | I | C | obstructive CAD. | |
| p.73 | I | C | Invasive coronary angiography is recommended in the evaluation of CAD in patients with severe ventricular SMR. | |
| p.73 | I | C | CABG is recommended in patients with a primary indication for valve surgery and coronary artery diameter stenosis ≥70%. | |
| p.73 | I | A | DOACs are recommended for stroke prevention in preference to VKAs in patients with AF and AS, AR, or MR who are eligible for OAC. | |
| p.73 | I | A | symptoms and recurrence of AF, according to an experienced team of electrophysiologists and arrhythmia surgeons. | |
| p.73 | I | B | cardioembolic stroke and systemic thromboembolism. | |
| p.73 | III | B | The use of DOACs is not recommended in patients with AF and rheumatic MS with an MVA ≤2.0 cm2. | |
| p.73 | I | B | AV surgery is recommended in symptomatic patients with severe AR regardless of LV function. | |
| p.73 | I | B | with small body size (BSA <1.68 m2)] or resting LVEF ≤50%. | |
| p.73 | I | B | results are expected. | |
| p.73 | I | B | AVA ≤1.0 cm2 (or ≤0.6 cm2/m2 BSA)]. | |
| p.73 | I | B | (<50%) after careful confirmation that AS is severe. | |
| p.73 | I | B | Intervention is recommended in asymptomatic patients with severe AS and LVEF <50% without another cause. | |
| p.73 | I | C | on-site interventional cardiology and cardiac surgical programmes, and a structured collaborative Heart Team. | |
| p.73 | I | C | characteristics, incorporating lifetime management considerations and estimated life expectancy. | |
| p.74 | I | A | TAVI is recommended in patients ≥70 years of age with tricuspid AV stenosis, if the anatomy is suitable. | |
| p.74 | I | B | SAVR is recommended in patients <70 years of age, if the surgical risk is low. | |
| p.74 | I | B | SAVR or TAVI are recommended for all remaining candidates for an aortic BHV according to Heart Team assessment. | |
| p.74 | I | C | SAVR is recommended in symptomatic and asymptomatic patients with severe AS undergoing CABG or surgical intervention on the ascending aorta. | |
| p.74 | I | B | MV repair is the recommended surgical technique to treat patients with severe PMR when the result is expected to be durable. | |
| p.74 | I | B | MV surgery is recommended in symptomatic patients with severe PMR considered operable by the Heart Team. | |
| p.74 | I | B | MV surgery is recommended in asymptomatic patients with severe PMR with LV dysfunction (LVESD ≥40 mm or LVESDi ≥20 mm/m2 or LVEF ≤60%). | |
| p.74 | I | B | MV surgery is recommended in patients with severe ventricular SMR undergoing CABG. | |
| p.74 | I | B | PMC is recommended in symptomatic patients in the absence of unfavourable characteristics for PMC. | |
| p.74 | I | C | PMC is recommended in any symptomatic patients with a contraindication or a high risk for surgery. | |
| p.74 | I | C | MV surgery is recommended in symptomatic patients who are not suitable for PMC. | |
| p.74 | I | C | and likelihood of recovery by a multidisciplinary Heart Team is recommended in patients with severe TR prior to intervention. | |
| p.74 | I | B | Concomitant TV surgery is recommended in patients with severe primary or secondary TR. | |
| p.74 | I | C | TV surgery is recommended in symptomatic patients with severe primary TR without severe RV dysfunction or severe PH. | |
| p.74 | I | C | Surgery is recommended in symptomatic patients with severe TS. | |
| p.74 | I | C | Surgery is recommended in patients with severe TS undergoing left-sided valve intervention. | |
| p.74 | I | C | SAVR is recommended in patients with severe AS undergoing surgery for another valve. | |
| p.74 | I | C | AV surgery is recommended in patients with severe AR undergoing surgery for another valve. | |
| p.74 | I | C | MV surgery is recommended in patients with severe MR undergoing surgery for another valve. | |
| p.75 | I | B | Intervention is recommended in symptomatic patients with mixed moderate AV stenosis and moderate regurgitation, and a mean gradient ≥40 mmHg or Vmax ≥4.0 m/s. | |
| p.75 | I | C | Intervention is recommended in asymptomatic patients with mixed moderate AV stenosis and moderate regurgitation with Vmax ≥4.0 m/s, and LVEF <50% not attributable to other cardiac disease. | |
| p.75 | I | C | An MHV is recommended according to the desire of the informed patient and if there is no contraindication to long-term anticoagulation. | |
| p.75 | I | C | A BHV is recommended according to the desire of the informed patient. | |
| p.75 | I | C | short life expectancy. | |
| p.75 | I | A | Lifelong OAC with a VKA is recommended for all patients with MHVs to prevent thromboembolic complications. | |
| p.75 | I | A | INR self-monitoring and self-management are recommended over standard monitoring in selected, trained patients to improve efficacy. | |
| p.75 | I | A | It is recommended that INR targets are based on the type and position of the MHV, and the patient’s risk factors and comorbidities. | |
| p.75 | I | A | Patient education is recommended to improve the quality of OAC. | |
| p.75 | I | B | considered safe. | |
| p.75 | III | A | DOACs and/or DAPT are not recommended to prevent thrombosis in patients with an MHV. | |
| p.75 | I | A | minimal bleeding. | |
| p.75 | I | B | within 24 h after surgery, or as soon as considered safe. | |
| p.75 | I | A | Low-dose ASA (75–100 mg/day) is recommended for 12 months after TAVI in patients without indication for OAC. | |
| p.75 | III | A | DAPT is not recommended to prevent thrombosis after TAVI, unless there is a clear indication. | |
| p.75 | III | A | Routine use of OAC is not recommended after TAVI in patients without baseline indication. | |
| p.75 | I | B | OAC continuation is recommended in patients with a clear indication for OAC undergoing surgical BHV implantation. | |
| p.75 | I | B | OAC is recommended for TAVI patients who have other indications for OAC. | |
| p.75 | I | C | evaluation, including patient risk, leak morphology, and local expertise. | |
| p.75 | I | C | Reoperation is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. | |
| p.75 | I | C | Reintervention is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. | |
| p.75 | I | C | TOE and/or 4D-CT are recommended in patients with suspected valve thrombosis to confirm the diagnosis. | |
| p.76 | I | B | Heart Team evaluation is recommended in patients with acute HF (NYHA class III or IV) due to obstructive MHV thrombosis to determine appropriate management (repeat valve replacement or low-dose slow infusion fibrinolysis). | |
| p.76 | I | B | OAC using VKA is recommended in BHV thrombosis before considering reintervention. |