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.......................................... 3.6.2 Atrial fibrillation Detailed recommendations on the management of patients with atrial fibrillation (AF) including management of anticoagulation are provided in specific guidelines.74 NOACs are recommended in patients with aortic stenosis, aortic regurgitation or mitral regurgitation presenting with AF7578 as subgroup analyses of randomized controlled trials (RCTs) support the use of apixaban, dabigatran, edoxaban, and rivaroxaban. The use of NOACs is not recommended in patients who have AF associated with clinically significant mitral stenosis or those with mechanical prostheses. Surgical ablation of AF combined with mitral valve surgery effectively reduces the incidence of AF but has no impact on adjusted short-term survival. An increased rate of pacemaker implantation has been observed after surgical ablation (9.5%, vs. 7.6% in the group with AF and no surgical ablation).79 Concomitant AF ablation should be considered in patients undergoing cardiac surgery, balancing the benefits of freedom from atrial arrhythmias with the risk factors for recurrence, such as age, LA dilatation, years in AF, renal dysfunction, and other cardiovascular risk factors. In addition, left atrial appendage (LAA) occlusion should be considered in combination with valve surgery in patients with AF and a CHA2DS2VASc score >_2 to reduce the thromboembolic risk.8082 The selected surgical technique should ensure complete occlusion of the LAA. For patients with AF and risk factors for stroke, long-term oral anticoagulation (OAC) is currently recommended, irrespective of the use of surgical ablation of AF and/or surgical LAA occlusion. Recommendations for the management of AF in native VHD are summarized in the following table. The recommendations concerning patients with valve prostheses, and the combination of anticoagulants and antiplatelet agents in patients undergoing PCI, are described in section 11 (section 11.3.2.2 and related table of recommendations for perioperative and postoperative antithrombotic management of valve replacement or repair). 3.7 Endocarditis prophylaxis Antibiotic prophylaxis should be considered for high-risk procedures in patients with prosthetic valves, including transcatheter valves, or with repairs using prosthetic material, and in patients with previous episode(s) of infective endocarditis.4 Particular attention to dental and cutaneous hygiene and strict aseptic measures during any invasive procedure are advised in this population. Antibiotic prophylaxis should be considered in dental procedures involving manipulation of the gingival or periapical region of the teeth or manipulation of the oral mucosa.4 Coronary angiography is recommended in the evaluation of severe SMR. I C Coronary CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD.d IIa C Indications for myocardial revascularization CABG is recommended in patients with a primary indication for aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis >_70%.e,f I C CABG should be considered in patients with a primary indication for aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis >_5070%. IIa C PCI should be considered in patients with a primary indication to undergo TAVI and coronary artery diameter stenosis >70% in proximal segments. IIa C PCI should be considered in patients with a primary indication to undergo transcatheter mitral valve intervention and coronary artery diameter stenosis >70% in proximal segments. IIa C CABG = coronary artery bypass grafting; CAD = coronary artery disease; CT = computed tomography; LV = left ventricle/left ventricular; PCI = percutaneous coronary intervention; SMR = secondary mitral regurgitation; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease. aClass of recommendation. bLevel of evidence. cChest pain, abnormal non-invasive testing. dCoronary CT angiography may also be used in patients requiring emergency surgery with acute infective endocarditis with large vegetations protruding in front of a coronary ostium. eStenosis >_50% can be considered for left main stenosis. fFFR <_0.8 is a useful cut-off indicating the need for an intervention in patients with mitral or tricuspid diseases, but has not been validated in patients with aortic stenosis. Adapted from45,72 Recommendations on management of atrial fibrillation in patients with native VHD Recommendations Classa Levelb Anticoagulation For stroke prevention in AF patients who are eligible for OAC, NOACs are recommended in preference to VKAs in patients with aortic stenosis, aortic and mitral regurgitation.7578,83,84 I A The use of NOACs is not recommended in patients with AF and moderate to severe mitral stenosis. III C Surgical interventions 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 dysfunction, and other cardiovascular risk factors).79,8590 IIa A LAA occlusion should be considered to reduce the thromboembolic risk in patients, with AF and a CHA2DS2VASc score >_2 undergoing valve surgery.82 IIa B AF = atrial fibrillation; LA = left atrium/left atrial; LAA = left atrial appendage; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulation; VKA = vitamin K antagonist. aClass of recommendation. bLevel of evidence. ESC/EACTS 2021 ESC/EACTS 2021 ................................................................................................................................... Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026