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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e153 CLINICAL STATEMENTS AND GUIDELINES

transvalvular, caused by leaflet immobility secondary to calcification or leaflet perforation or flail associated with areas of focal calcification.1 Echocardiographic definitions of prosthetic valve regurgitation severity have been published by the American Society of Echocardiography.2

11.9.1 Diagnosis of Prosthetic Valve Regurgitation

Recommendations for Diagnosis of Prosthetic Valve Regurgitation Referenced studies that support the recommendations are summarized in Online Data Supplement 41. COR LOE Recommendations

1 B-NR 1.  In patients with suspected mechanical or bioprosthetic valve regurgitation, TTE and TEE are recommended to determine the cause and severity of the leak, assess ventricular function, and estimate pulmonary artery systolic pressure.1–4

1 C-EO 2.  In patients undergoing a transcatheter procedure for paravalvular prosthetic regurgitation, 3D TEE is recommended for intraprocedural guidance.4–7 Synopsis

The clinical presentation of prosthetic valve regurgitation varies depending on its severity, hemodynamic effects, and etiology. In asymptomatic patients, prosthetic valve regurgitation may be found incidentally on routine clinical or imaging follow-up. A change in auscultatory findings (eg, change in prosthetic valve sounds or a new murmur) should prompt suspicion of prosthetic valve dysfunction. Symptomatic patients with prosthetic valve regurgitation present with unexplained or new-onset HF or significant hemolysis with or without anemia. TTE is inadequate for evaluation of prosthetic mitral valves; TEE is needed when prosthetic MR is a concern. A critical step in evaluation of the patient with prosthetic valve regurgitation is to distinguish transvalvular from paravalvular leak, which also requires TEE in addition to TTE.

Figure 14. Management of prosthetic valve stenosis and regurgitation. Colors correspond to Table 2. 3D indicates 3-dimensional; 4D, 4-dimensional; CT, computed tomography; CVC, Comprehensive Valve Center; HF, heart failure; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography/echocardiogram; and ViV, valve-in-valve. *See Figure 13 if valve thrombosis is suspected.

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