Heart valve diseases are an important group of cardiovascular diseases. In recent years, significant advances have been made in the diagnosis and treatment of heart valve disease, and the ACC and AHA published the Guidelines for the Management of Heart Valve Disease (2006 Revision) in August 2006, which cover all aspects of the diagnosis and treatment of heart valve disease, reflecting the latest advances in the field and serving as a programmatic document to guide clinical practice in valve disease.
General Principles
1. Strong indications for echocardiography
1.1. Asymptomatic patients with diastolic heart murmurs, continuous heart murmurs, total systolic heart murmurs, late systolic heart murmurs, heart murmurs associated with jet clicks, or heart murmurs radiating to the neck or back.
1.2. Patients with heart murmurs with signs or symptoms of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditis, or other clinical manifestations of organic heart disease.
1.3. Asymptomatic patients with a grade 3 mid-systolic heart murmur.
2. Strong indications for endocarditis prophylaxis
2.1. Patients with prosthetic heart valves and a history of infective endocarditis
2.2. Patients with complex cyanotic congenital heart disease (i.e., single ventricle, transposition of the great arteries, and Fallot’s tetralogy).
2.3. Patients with surgical procedures to establish a body-pulmonary circulation shunt.
2.4. Patients with congenital heart valve malformations, particularly those with aortic bicuspid valve malformations, and acquired valve insufficiency (i.e., rheumatic heart disease).
2.5. Patients who have undergone valve repair.
2.6. Patients with occult or resting obstruction in hypertrophic cardiomyopathy.
2.7. Patients with mitral valve prolapse and with valve regurgitation on auscultation and/or valve leaflet thickening on echocardiography.
3. Strong indications for secondary prevention of rheumatic fever. Patients with rheumatic fever with or without cardiac inflammation (including patients with mitral stenosis) should receive prophylaxis to prevent recurrence of rheumatic fever.
Special heart valve damage
1. Aortic stenosis
1.1. strong indications for echocardiography (imaging, spectroscopy, and color Doppler)
1, Diagnosis and assessment of the severity of aortic stenosis.
2, Assessment of left ventricular wall thickness, size, and function in patients with aortic stenosis.
3, Re-evaluation of patients with a definite diagnosis of aortic stenosis and changes in symptoms or signs.
4, To assess the hemodynamic severity and left ventricular function during pregnancy in patients with aortic stenosis.
5.Apply transthoracic echocardiography to re-evaluate asymptomatic patients: once a year for severe aortic stenosis; once every 1 to 2 years for moderate aortic stenosis; and once every 3 to 5 years for mild aortic stenosis.
1.2. Strong indications for cardiac catheterization
1, Patients with aortic stenosis at risk for coronary artery disease and coronary angiography before aortic valve replacement.
2. Cardiac catheterization is used to measure hemodynamics to assess the severity of aortic stenosis in symptomatic patients with uncertain noninvasive test results or when noninvasive tests are inconsistent with clinical findings to determine the severity of aortic stenosis.
3. Coronary angiography is performed before aortic valve replacement in patients with aortic stenosis who are considered for pulmonary autograft (Ross procedure) and in whom noninvasive testing cannot detect a coronary origin.
1.3. Assessment of relative indications for low-flow/low-pressure differential aortic stenosis
1. Dobutamine loading echocardiography can be performed to evaluate patients with low-flow/low-pressure aortic stenosis and left ventricular insufficiency.
2. Cardiac catheterization using a dobutamine drip method to measure hemodynamics is useful in the evaluation of patients with low-flow/low-pressure aortic stenosis and left ventricular insufficiency.
1.4. Strong Indications for Aortic Valve Replacement
1, Patients with symptomatic severe aortic stenosis.
2, Patients with severe aortic stenosis undergoing surgical coronary artery bypass grafting.
3, Patients with severe aortic stenosis undergoing surgical procedures such as aortic valve leaflet surgery.
4, Patients with severe aortic stenosis and left ventricular systolic insufficiency (ejection fraction <0.50).
1.5 Relative indications for aortic balloon valvuloplasty
1, Adult patients with hemodynamically unstable aortic stenosis who are at high risk for aortic valve replacement may undergo aortic balloon valvuloplasty as a bridge to subsequent surgical procedures.
2, Aortic balloon valvuloplasty can be performed as palliative treatment in adult patients with aortic stenosis when aortic valve replacement cannot be performed due to severe co-morbidities.
2. Aortic regurgitation
2.1. Strong indications for diagnosis and initial evaluation
1. Echocardiography should be used to confirm the presence and severity of acute or chronic aortic regurgitation.
2. Echocardiography should be used to confirm the diagnosis and assess the cause of chronic aortic regurgitation (including valve morphology and aortic root size and morphology) and should be used to assess left ventricular hypertrophy, size (i.e., volume), and systolic function.
3, Echocardiography should be used in patients with an enlarged aortic root to assess the severity of regurgitation and aortic enlargement.
4. Echocardiography should be used in patients with asymptomatic severe aortic regurgitation for periodic reassessment of left ventricular size and function.
5. Nuclear angiography or magnetic resonance imaging should be used for initial and serial assessment of left ventricular volume and function at rest in patients with aortic regurgitation and in those with abnormal echocardiography.
6. Echocardiography should be used for reassessment of mild, moderate, or severe aortic regurgitation in patients with new onset or changing symptoms.
2.2. Strong Indications for Drug Therapy
Long-term vasodilator therapy is indicated in patients with severe aortic regurgitation with symptoms or left ventricular insufficiency when surgical treatment is not indicated due to cardiac or noncardiac factors.
2.3. Strong indications for cardiac catheterization
1. In patients with arterial regurgitation, when noninvasive tests cannot make a conclusion or do not match the clinical presentation, cardiac catheterization such as aortic root angiography and measurement of left ventricular pressure is indicated to assess the severity of regurgitation, left ventricular function or aortic root size.
2. Patients at risk for coronary artery disease have indications for coronary angiography before aortic valve replacement.
2.4. Strong indications for aortic valve replacement or aortic repair
1, Patients with symptomatic severe aortic regurgitation, regardless of left ventricular systolic function status.
2. Asymptomatic patients with chronic severe aortic regurgitation and resting left ventricular systolic insufficiency (ejection fraction £0.50).
3, Patients with chronic severe aortic regurgitation undergoing surgical coronary artery bypass grafting or aortic and other heart valve surgery.
3. Strong indications for dilatation of the ascending aorta with aortic diastasis
3.1. Patients with known aortic valvular diastasis should have an initial transthoracic echocardiogram to determine the diameter of the aortic root and ascending aorta.
3.2. Patients with aortic diastasis whose aortic root or ascending aortic morphology cannot be determined by echocardiography are indicated for cardiac magnetic resonance imaging or cardiac computed tomography.
3.3. Patients with aortic diastasis and an enlarged aortic root or ascending aorta (>4.0 cm in diameter) should have serial assessment of the size and morphology of the aortic root/ascending aorta using echocardiography, cardiac magnetic resonance imaging, or computed tomography once a year.
3.4. Patients with diastolic aortic valve malformation who have an aortic root or ascending aorta >5.0 cm in diameter or a diameter increase rate of 30.5 cm/year are indicated for surgical repair of the aortic root or replacement of the ascending aorta.
3.5 Patients with diastolic valve malformation due to severe aortic stenosis or aortic regurgitation resulting in regurgitation are indicated for repair of the aortic root or replacement of the ascending aorta if the aortic root or ascending aorta is >4.5 cm in diameter.
4. Mitral stenosis
4.1. Strong indications for mitral stenosis echocardiography
1, Patients diagnosed with mitral stenosis, to assess their hemodynamic severity (to evaluate pressure step difference, mitral valve area, and pulmonary artery pressure), to assess concomitant valve damage, and to assess valve morphology (to determine suitability for percutaneous mitral balloon valvuloplasty).
2, Reevaluation of patients with known mitral stenosis, with symptoms and signs.
3, Patients with mitral stenosis, when resting Doppler echocardiographic evidence, clinical evidence, and symptoms and signs are inconsistent, exercise stress echocardiography should be performed to assess mean pressure step difference and pulmonary artery pressure.
4, In patients with mitral stenosis, transesophageal echocardiography should be performed to assess the presence of left atrial thrombus and to further assess the severity of mitral regurgitation in patients being considered for percutaneous mitral balloon valvuloplasty.
5. When transthoracic echocardiography does not provide adequate clinical data in patients with mitral stenosis, transesophageal echocardiography should be performed to assess mitral valve morphology and hemodynamics.
4.2. anticoagulation therapy
1. Patients with mitral stenosis and atrial fibrillation (paroxysmal, persistent, or permanent).
2. Patients with mitral stenosis with previous embolic events, even in sinus rhythm.
3. Patients with mitral stenosis with left atrial thrombus.
4.3. Indications for invasive hemodynamic evaluation
1, Cardiac catheterization should be performed to assess hemodynamics and thus the severity of mitral stenosis if noninvasive findings are inconclusive or if there is disagreement between noninvasive findings and clinical examination for assessing the degree of mitral stenosis.
2. Patients with mitral stenosis in whom Doppler mean pressure step difference and valve area measurements are inconsistent have indications for cardiac catheterization for hemodynamic evaluation, including left ventriculography (to assess the severity of mitral regurgitation).
4.4. strong indications for percutaneous mitral balloon valvuloplasty
1, Patients with symptomatic (cardiac function NYHA class II, III, or IV) moderate or severe mitral stenosis* and valve morphology suitable for percutaneous mitral balloon valvuloplasty without left atrial thrombus or moderate or severe mitral regurgitation.
2. Patients with asymptomatic moderate or severe mitral stenosis* and mitral valve morphology suitable for percutaneous mitral balloon valvuloplasty, pulmonary hypertension (systolic pulmonary artery pressure >50 mmHg at rest or >60 mmHg with exercise), and no left atrial thrombus or moderate or severe mitral regurgitation.
4.5. Strong indications for mitral stenosis surgery
1. Patients with symptomatic (NYHA functional class III-IV) moderate or severe mitral stenosis for whom mitral valve surgery (and repair, if possible) is indicated in the following cases: (1) patients without the ability to perform percutaneous mitral balloon valvuloplasty; (2) patients with left atrial thrombus or moderate or severe mitral regurgitation despite anticoagulation, contraindicating percutaneous mitral balloon valvuloplasty; (3) patients with certain patients with certain surgical risks and valve morphology not suitable for percutaneous mitral balloon valvuloplasty.
Patients with symptomatic moderate or severe mitral stenosis* with moderate or severe mitral regurgitation should undergo mitral valve replacement surgery, unless a valve repair can be performed during surgery.
5. Mitral valve prolapse
5.1. Evaluation and management of asymptomatic patients Patients with signs of mitral valve prolapse who are asymptomatic are indicated for echocardiography to diagnose mitral valve prolapse and to assess mitral regurgitation, leaflet morphology, and left ventricular compensation.
5.2. Evaluation and management of symptomatic patients
1, Symptomatic patients with mitral valve prolapse who have had a transient ischemic attack are recommended to be treated with aspirin (75 to 325 mg/day).
2, In patients with mitral valve prolapse with atrial fibrillation, warfarin therapy is recommended for patients >65 years of age or patients with hypertension, mitral regurgitation murmur, or a history of heart failure.
3, Aspirin therapy (75 to 325 mg/day) is recommended for patients with mitral valve prolapse with atrial fibrillation, age <65 years, and no history of mitral regurgitation or heart failure.
4, In patients with mitral valve prolapse with a history of stroke, warfarin therapy is recommended for patients with mitral regurgitation, atrial fibrillation, or left atrial thrombus.
6. Mitral regurgitation
6.1. indications for transthoracic echocardiography
1, In patients with suspected mitral regurgitation, to assess left ventricular size and function, right ventricular and left atrial area, pulmonary artery pressure, and severity of mitral regurgitation.
2, To understand the specific status of mitral regurgitation.
3, Patients with asymptomatic moderate or severe mitral regurgitation have indications for transthoracic echocardiography once every six months or once a year to monitor the status of left ventricular function (by ejection fraction and end-diastolic internal diameter).
4, Evaluate mitral annular condition and left ventricular function in patients with mitral regurgitation when symptoms or signs change.
5. After mitral valve replacement or mitral valve repair, assess left ventricular size and function and mitral valve hemodynamics.
6.2. indications for transesophageal echocardiography
1, To assess the feasibility of valve repair and to guide patients undergoing repair to establish an anatomic basis for the evaluation of severe mitral stenosis.
2. Patients in whom transthoracic echocardiography does not provide diagnostic information on the severity of mitral regurgitation, the underlying mitral regurgitation, and/or the functional status of the left ventricle.
6.3. Indications for cardiac catheterization
1. When the severity of mitral regurgitation, left ventricular function, or the need for surgical treatment cannot be determined by noninvasive testing, left ventriculography and hemodynamic measurements are indicated.
2. When noninvasive evaluation shows that pulmonary hypertension is disproportionate to the severity of mitral regurgitation, hemodynamic testing is indicated.
3.For determining the degree of severe mitral regurgitation, left ventriculography and hemodynamic measurements are indicated when the clinical manifestations are not consistent with the noninvasive results.
4. In patients at high risk for coronary artery disease, coronary angiography is indicated before mitral valve repair or mitral valve replacement.
6.4. Strong indications for mitral valve surgery
1. Patients with symptomatic acute severe mitral regurgitation.
2, Patients with chronic severe mitral regurgitation* and cardiac function NYHA class II, III, or IV without severe LV insufficiency (severe LV insufficiency is defined as ejection fraction <0.30) and/or end-systolic internal diameter >55 mm.
3, Patients with asymptomatic chronic severe mitral regurgitation*, mild or moderate left ventricular insufficiency, ejection fraction 0.30-0.60 and/or end-systolic internal diameter ≥40 mm.
4, Most patients with severe chronic mitral regurgitation* requiring surgery are recommended for mitral valve repair rather than mitral valve replacement, and patients should visit a surgical center experienced in mitral valve repair.