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

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e158

CLINICAL STATEMENTS AND GUIDELINES modalities involved, ideally at centers with immediate access to cardiac surgery during the initial observation stages of the disease. With the emerging use of telemedicine, it may be reasonable to manage patients with lower-acuity IE in a center without on-site multispecialty care by telecommunication with a Heart Valve MDT and infectious disease specialists, with rapid transfer of the patient to a Comprehensive Valve Center if needed.11–13

5.	 The presence of valvular vegetation is a major criterion in the diagnosis of IE. TTE has a sensitivity between 50% and 90% and a specificity >90% for detection of vegetations in native valve endocarditis. TTE has a sensitivity of only 36% to 69% in prosthetic valve endocarditis, but TTE still has a role in these patients for detection and quantitation of valve dysfunction (even in the challenging situation of regurgitation in the mechanical prosthetic mitral valve, for which a proximal convergence zone may provide important evidence for a paravalvular leak), evaluation of ventricular size and systolic function, and estimation of pulmonary pressures. TTE exhibits superior imaging over TEE for the anterior aspect of a prosthetic aortic valve, which is commonly shadowed by the valve on TEE. TTE also allows measurement of aortic transvalvular velocity/ gradient, which is not always possible on TEE. Although TTE will not definitively exclude vegetations or abscesses in IE, it can identify very high-risk patients, establish the diagnosis, and guide early treatment decisions (Figure 8).14,19–23 6.	 The sensitivity of TEE in native valve endocarditis ranges from 90% to 100%, with sensitivity ranges slightly lower in prosthetic valve endocarditis. TEE is superior to TTE in the visualization of both vegetations and paravalvular complications, which can be anatomic (eg, valve perforation, abscesses, and pericardial effusion) or hemodynamic (eg, valve regurgitation, fistulae, and intracardiac thrombi) in nature. TTE and TEE are complementary for the comprehensive evaluation of hemodynamics and anatomy in patients with IE. TEE should be used as an adjunct in patients with echocardiographic features of IE on TTE to rule out the presence of findings such as abscesses, which may alter the therapeutic approach to the management of the patient. TEE also serves a vital role in reassessment of patients with known IE with suspected clinical complications, as well as a guiding tool in the intraoperative assessment and management of the patient with IE. The timing of repeat examinations depends on the clinical presentation and course and on the virulence of the microorganism. Increasing vegetation size under therapy must be considered a risk factor for new embolic events, whereas unchanged or reduced vegetation size under therapy may be more difficult to interpret.23,29,32–40

7.	 HF, paravalvular extension, and embolic events represent the 3 most frequent and severe complications of IE. They are also the 3 main indications for early surgery, which is performed in almost 50% of cases. If signs or symptoms consistent with any of these complications exist, there should be a very low threshold for repeat imaging in these patients. TEE may miss initial paravalvular abscesses, particularly when the study is performed early in the patient’s illness. In such cases, the incipient abscess may be seen only as nonspecific paravalvular thickening, which on repeat imaging across several days may become recognizable as it expands and cavitates. Similarly, paravalvular fistulae and pseudoaneurysms develop over time, and negative early TEE images do not exclude the potential for their development. A single negative TEE study cannot rule out underlying IE, and a repeat TEE study should be performed when a suspicion of persistence of infection remains or if complications ensue. Conversely, in the absence of clinical deterioration or new signs and symptoms, routine follow-up echocardiography is probably of only limited clinical utility.24,41,42,44–46 8.	 Intraoperative TEE during cardiac surgery has an important role in the evaluation and quality control of a large variety of pathologies. Clinical and echocardiographic characteristics may change during an episode of IE because of the prolonged active phase and fluctuating course of this disease. Even if preoperative TEE has been performed, vegetation change/embolization or extension of the infectious process beyond the valve tissue may occur. In addition, other valves may become involved as the disease timeline progresses. Intraoperative TEE has been invaluable for baseline reassessment of anatomic or hemodynamic changes that may occur in the interval between the diagnostic echocardiogram and the time of surgery. TEE is also an important monitoring tool for evaluation of operative complications, such as air emboli, and an important adjunct to ensure the quality of the intended surgical result.49,50 9.	 The recently published randomized POET (Partial Oral Treatment of Endocarditis) trial studied 400 patients with “stable” left-sided IE caused by streptococcus, Enterococcus faecalis, S. aureus, or coagulase-negative staphylococci. Patients who had been on intravenous antibiotics for at

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