Heart valve diseases are an important group of cardiovascular diseases. In recent years, significant progress has been made in the diagnosis and treatment of heart valve diseases. the ACC and AHA published the Guidelines for the Treatment of Heart Valve Diseases (2006 Revised Edition) in August 2006, which cover all aspects of the diagnosis and treatment of heart valve diseases, reflecting the latest advances in the field and serving as a programmatic document to guide the clinical practice of valve diseases. I. General Principles 1.1 Strong Indications for Echocardiography Zhang Dafa, Department of Thoracic Surgery, Yiji Shan Hospital, Wanan Medical College 1, Asymptomatic patients with diastolic heart murmur, continuous heart murmur, total systolic heart murmur, late systolic heart murmur, heart murmur associated with jet karate, or heart murmur radiating to the neck or back. 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. 3. Asymptomatic patients with a mid-systolic cardiac murmur of grade 33. 1.2 Strong indications for endocarditis prophylaxis 1, Patients with prosthetic heart valves and a history of infective endocarditis. 2, Patients with complex cyanotic congenital heart disease (i.e., single ventricle, transposition of the great arteries, and Fallot’s tetralogy of Fallot). 3, Patients with surgical procedures to establish a body-pulmonary circulation shunt. 4, Patients with congenital heart valve malformations, especially those with aortic diastasis, and acquired valve insufficiency (i.e., rheumatic heart disease). 5, Patients who have had valve repair. 6, Patients with hypertrophic cardiomyopathy with occult or resting obstruction. 7, Patients with mitral valve prolapse and with valve regurgitation on auscultation and/or valve leaflet thickening on echocardiography. 1.3 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. II. Specific heart valve damage 2.1 Aortic stenosis 2.1.1 Strong indications for echocardiography (imaging, spectroscopy, and color Doppler) 1. Diagnosis and assessment of the severity of aortic stenosis. 2.To assess the thickness, size, and function of the left ventricular wall in patients with aortic stenosis. 3.Reevaluate patients with a definite diagnosis of aortic stenosis and a change 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. 2.1.3 Strong indications for cardiac catheterization 1, Patients with aortic stenosis at risk for coronary artery disease and coronary angiography before aortic valve replacement 2, When the results of noninvasive testing in symptomatic patients are uncertain or when noninvasive testing is inconsistent with clinical findings to determine the severity of aortic stenosis, cardiac catheterization is used to measure hemodynamics to assess the severity of aortic stenosis. 3. When patients with aortic stenosis are considered for pulmonary autotransplantation (Ross procedure) and noninvasive tests cannot detect the coronary origin, coronary angiography is performed before aortic valve replacement. 2.1.4 Relative Indications for Assessment of Low-Flow/Poor-Pressure Aortic Stenosis 1. Dobutamine loading echocardiography can be evaluated in 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. 2.1.5 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 for aortic valve and other valve leaflet surgery. 4, Patients with severe aortic stenosis and left ventricular systolic insufficiency (ejection fraction <0.50). 2.1.6 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, When aortic valve replacement cannot be performed in adult patients with aortic stenosis due to severe co-morbidities, aortic balloon valvuloplasty can be performed as palliative treatment. 2.2 Aortic regurgitation 2.2.1 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 aortic root enlargement 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. 2.2.2 Strong Indications for Pharmacologic Therapy Patients with severe aortic regurgitation with symptoms or left ventricular insufficiency have indications for long-term vasodilator therapy when surgical treatment is not indicated due to cardiac or noncardiac factors. 2.2.3 Strong indications for cardiac catheterization indications 1. Patients with aortic regurgitation, when noninvasive tests cannot make conclusions or do not match the clinical presentation, have indications for cardiac catheterization such as aortic root angiography and measurement of left ventricular pressure 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 prior to aortic valve replacement. 2.2.4 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 heart valve surgery such as aortic. 2.3 Strong indications for ascending aortic dilatation with aortic diastasis 1, Patients with known aortic diastasis should have an initial transthoracic echocardiogram to determine the diameter of the aortic root and ascending aorta. 2, Patients with aortic diastasis whose aortic root or ascending aorta morphology cannot be determined by echocardiography are indicated for cardiac magnetic resonance imaging or cardiac computed tomography. 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. 4. Patients with aortic diastasis 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. 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 diameter of the aortic root or ascending aorta is >4.5 cm. 2.4 Mitral stenosis 2.4.1 Strong indications for mitral stenosis echocardiography 1, Patients diagnosed with mitral stenosis, assessment of their hemodynamic severity (assessment of pressure step difference, mitral valve area, and pulmonary artery pressure), assessment of concomitant valvular damage, and assessment of valve morphology (to determine suitability for percutaneous mitral balloon angioplasty) 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. 2.4.2 Anticoagulation 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. 2.4.3 Indications for invasive hemodynamic evaluation 1, When noninvasive findings are inconclusive or when noninvasive findings disagree with clinical examination in assessing the degree of mitral stenosis, cardiac catheterization should be performed to assess hemodynamics and thus the severity 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). 2.4.4 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. 2.4.5 Strong indications for mitral stenosis surgery 1. Patients with symptomatic (NYHA functional class III-IV) moderate or severe mitral stenosis in whom mitral valve surgery (and repair if possible) is indicated: (i) without the ability to perform percutaneous mitral balloon valvuloplasty; (ii) with left atrial thrombus despite anticoagulation, or with moderate or severe mitral regurgitation. Percutaneous mitral balloon valvuloplasty is contraindicated; (3) patients with certain surgical risks and valve morphology not suitable for percutaneous mitral balloon valvuloplasty. 2. Patients with moderate or severe mitral regurgitation who have symptomatic moderate or severe mitral stenosis* should undergo mitral valve replacement surgery, unless surgery is performed when valve repair can be performed. 2.5 Mitral valve prolapse 2.5.1 Evaluation and management of asymptomatic patients In patients with signs of mitral valve prolapse without symptoms, echocardiography is indicated to diagnose mitral valve prolapse and to assess mitral regurgitation, leaflet morphology, and left ventricular compensation. 2.5.2 Evaluation and management of symptomatic patients 1, Symptomatic patients with mitral valve prolapse who have had transient ischemic attacks are recommended to be treated with aspirin (75-325 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. 2.6 Mitral regurgitation 2.6.1 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 6 months or once a year to monitor the status of left ventricular function (via ejection fraction and end-diastolic internal diameter). 4, Assessment of 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. 2.6.2 Indications for Transesophageal Echocardiography 1, To assess the feasibility of valve repair and to guide patients undergoing repair to establish an anatomic basis for evaluating 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. 2.6.3 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 examination, 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. 2.6.4 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 LV insufficiency, ejection fraction 0.30 to 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 with experience in mitral valve repair. 2.7 Tricuspid Valve Disease 2.7.1 Management Tricuspid valve repair is beneficial in patients with mitral valve disease requiring mitral valve surgery in conjunction with severe tricuspid regurgitation. III. Evaluation and management of infective endocarditis Patients at risk for infective endocarditis with unexplained fever for more than 48 h should have at least 2 blood cultures from different sites. 3.1 Strong indications for transthoracic echocardiography in endocarditis 1, Detection of valvular redundancy with or without positive blood cultures and diagnosis of infective endocarditis. 2, In patients with known infective endocarditis, to determine the severity of hemodynamic changes due to valve damage 3, Evaluate for complications of infective endocarditis (eg, abscesses, perforations, and shunts). 4. Re-evaluate patients at high risk (e.g., strong virulent causative organisms, clinical deterioration, persistent or recurrent fever, emerging murmurs, or persistent bacteremia). 3.2 Strong indications for transesophageal echocardiography in endocarditis 1. Transesophageal echocardiography is done when transthoracic echocardiography is not diagnostic to assess the severity of valve damage in patients with symptomatic infective endocarditis. 2. If transthoracic echocardiography is not diagnostic, transesophageal echocardiography is done to diagnose heart valve disease and positive blood cultures in patients with infective endocarditis. 3, To diagnose the potential prognostic and therapeutic impact of complications of infective endocarditis (e.g., abscesses, perforations, and shunts) 4, As a first-line diagnostic test for the diagnosis of prosthetic endocarditis and to assess complications 5, Preoperative evaluation of patients with known infective endocarditis, unless transthoracic echocardiography indicates the need for surgical procedures, unless preoperative imaging may delay surgical management of acute cases 6, in surgical valve surgery in patients with infective endocarditis. 3.3 Strong Indications for Surgery for Autologous Valve Endocarditis 1, Patients with acute infective endocarditis with stenosis or regurgitation leading to heart failure. 2, Patients with acute infective endocarditis with aortic valve or with hemodynamic evidence of elevated left ventricular diastolic unpressure or left atrial pressure [i.e., pre-term mitral valve closure in the presence of aortic regurgitation, rapidly decreasing mitral regurgitation signal (υ-wave truncation) in the continuous Doppler spectrum, and moderate to severe pulmonary hypertension]. 3, Patients with infected endocarditis caused by fungi or other recalcitrant microorganisms. 4, Patients with combined heart block, annular or aortic valve abscess or destructive penetrating injury (e.g., aortic sinus to right atrium, right ventricle or left atrium fistula, mitral leaflet perforation in aortic valve endocarditis, or annular fibrotic infection). 3.4 Strong indications for surgery for prosthetic valve endocarditis 1, Patients with prosthetic valve infective endocarditis should be seen by a cardiac surgeon. 2, Patients with prosthetic valve endocarditis in heart failure. 3, Patients with prosthetic valve infective endocarditis with fissures demonstrated by cine fluoroscopy or echocardiography. 4, Patients with infective endocarditis with increased obstruction or increased regurgitation. 5, Patients with complications such as abscess formation of prosthetic valve infective endocarditis. IV. Management of valve disease during pregnancy 4.1 Choice of anticoagulation regimen during pregnancy in patients with mechanical prosthetic valves 1. must receive continuous anticoagulation therapy and be monitored frequently. 2. When women requiring long-term warfarin anticoagulation are preparing for pregnancy, pregnancy tests must be monitored to determine subsequent anticoagulation therapy, and anticoagulation may be uninterrupted after pregnancy. 3. Warfarin should be discontinued during 6-12 weeks of gestation, receive continuous intravenous heparin, and adjust the dose of heparin or low molecular heparin. 4. The choice of continuous intravenous heparin or adjusted transdermal heparin dose, adjusted low-molecular heparin dose or warfarin should all be fully discussed at 36 weeks of gestation. The risk of fatalities is low if heparin is applied continuously, but the risk of maternal prosthetic valve thrombosis, body circulation embolism, infection, osteoporosis, and heparin-induced thrombocytopenia is relatively high. 5, When receiving dose-adjusted low molecular heparin, low molecular heparin should be administered subcutaneously 2 times/day to maintain anti-Xa levels at 0.7-1.2u/ml 4h after injection. 6, When receiving dose-adjusted heparin, aPTT should be at least 2 times that of the control group. 7, Receiving warfarin therapy, INR value should be 3.0 (range 2.5~3.5). 8.When the machine is 2~3 weeks before the planned delivery, warfarin should be terminated and replaced by continuous intravenous heparin therapy. V. Management of congenital heart valve disease in adolescents and young adults 5.1 Strong indications for evaluation of asymptomatic aortic stenosis in adolescents and young adults 1. Doppler mean pressure step difference >30 mmHg, or peak flow velocity >3.5 m/s (peak pressure >50 mmHg) with annual electrocardiogram examination. If Doppler mean pressure step difference ≤ 30 mmHg or peak flow rate ≤ 3.5 m/s (peak pressure ≤ 50 mmHg) by echocardiography, check once every 2 years. 2, Doppler mean pressure step difference >30mmHg, or peak flow rate >3.5m/s (peak pressure >50mmHg), check Doppler echocardiography examination every year. If Doppler mean pressure step difference ≤ 30 mmHg or peak flow velocity ≤ 3.5 m/s (peak pressure ≤ 50 mmHg) by echocardiography, check once every 2 years. 3, When the results of Doppler echocardiography do not clarify the degree of aortic stenosis, or when clinical manifestations are inconsistent with the results of noninvasive examination, cardiac catheterization is an effective diagnostic tool to assess aortic stenosis. 4, With symptoms of angina, syncope, or exertional dyspnea, cardiac catheterization is indicated if the mean Doppler pressure step difference is >30 mmHg or if the peak flow velocity is >3.5 m/s (peak pressure >50 mmHg). 5. If T-wave inversion in the left thoracic lead occurs at rest, and if the mean Doppler pressure step difference is >30 mmHg, or the peak flow rate is >3.5 m/s (peak pressure >50 mmHg), cardiac catheterization is indicated. 5.2 Strong Indications for Aortic Balloon Valvuloplasty in Adolescents and Young Adults 1, Adolescents and young adults with arterial stenosis, angina, syncope, exertional dyspnea, and catheterization showing a peak left ventricular/aortic pressure gradient of ≥50 mmHg without severe valvular calcification. 2. asymptomatic adolescents and young adults with aortic stenosis and catheterization showing a peak left ventricular/aortic pressure gradient >60 mmHg. 3. asymptomatic adolescents and young adults with aortic stenosis and left thoracic lead ST-T wave inversion at rest or during exercise and catheterization showing a peak left ventricular/aortic pressure gradient >50 mmHg. 5.3 Aortic regurgitation aortic valve Strong indications for repair or replacement 1, Adolescents or young adults with chronic severe aortic regurgitation* with symptoms of angina pectoris, syncope, or exertional dyspnea. 2, Chronic severe aortic regurgitation* in asymptomatic adolescents or young adults with abnormal left ventricular systolic function (ejection fraction <0.5) on multiple examinations 1 to 3 months apart. 3, Chronic severe aortic regurgitation* asymptomatic adolescent or young adult with progressive left ventricular enlargement (left ventricular end-diastolic volume up to 4 standard deviations from normal) 4.Patients with adolescent or young adult aortic regurgitation who are proposed for pulmonary valve autografting (Ross procedure) and whose coronary artery initiation is not detected by noninvasive means are recommended to undergo coronary angiography before aortic valve replacement. 5.4 Strong indications for mitral regurgitation mitral valve surgery 1, NYHA cardiac function class III-IV, adolescent and young adult patients with symptomatic severe congenital mitral regurgitation*. 2, In asymptomatic adolescent and young adult patients with severe congenital mitral regurgitation and abnormal left ventricular systolic function (ejection fraction ≤ 0.60). 5.5 Strong indications for mitral valve surgery for mitral stenosis Adolescent and young adult patients with congenital mitral stenosis who are symptomatic (NYHA cardiac function class III-IV) or have a mean mitral pressure step difference >10 mm Hg on Doppler echocardiography. 5.6 Evaluation of tricuspid valve disease in adolescents and young adults 1. Initial evaluation of adolescent and young adult patients with tricuspid regurgitation with indications for an electrocardiogram, which is reviewed every 1 to 3 years depending on the severity. 2. Initial evaluation of adolescent and young adult patients with tricuspid regurgitation, with indication for chest x-ray, to be repeated every 1 to 3 years depending on the severity. 3, Initial evaluation of adolescent and young adult patients with tricuspid regurgitation, with indication for Doppler echocardiography, to be reviewed every 1 to 3 years depending on the severity. 4.4 Initial evaluation of adolescent and young adult patients with tricuspid regurgitation with indications for rest and/or pulse oximetry during exercise, and review every 1 to 3 years. 5.7 Strong indications for surgical treatment of tricuspid regurgitation 1. Adolescent and young adult patients with worsening physical activity tolerance (NYHA class III or IV). 2, Adolescent and young adult patients with progressive cyanosis and arterial oxygen saturation <80% at rest or during exercise. 3. Adolescent and young adult patients with tricuspid regurgitation, hypoxia at rest and worsening hypoxemia during exercise resulting in exercise intolerance, and if surgical repair of the tricuspid valve seems difficult, interventional catheterization to seal interatrial traffic. 5.8 Evaluation of Pulmonary Stenosis in Adolescents and Young Adults 1, When first evaluating adolescent and young adult patients with pulmonary stenosis, an electrocardiogram is recommended, with a review every 5 to 10 years. 2, For the initial evaluation of adolescent and young adult patients with pulmonary stenosis, transthoracic Doppler echocardiography is recommended, with a review every 5 to 10 years. 3. In adolescent and young adult patients with pulmonary stenosis, if the peak Doppler jet rate is >3 m/s (estimated peak gradient >36 mmHg), cardiac catheterization is recommended at initial evaluation, and if appropriate, balloon dilation can be performed. 5.9 Strong indications for balloon valvuloplasty for pulmonary stenosis 1. Adolescent and young adult patients with pulmonary stenosis with exertional dyspnea, angina pectoris, and presyncopal state and cardiac catheterization showing right ventricle-pulmonary artery peak pressure gradient >30 mmHg. 2. Adolescent and young adult patients with asymptomatic pulmonary stenosis with catheterization showing right ventricle-pulmonary artery peak pressure gradient > 40 mmH. VI. Surgery 6.1 Main criteria for aortic valve selection 1. Patients with a mechanical valve in the mitral or tricuspid position are recommended to apply the mechanical valve. 2. For patients of any age who are unwilling to take oral warfarin or who are aware of contraindications to warfarin therapy, the use of a biosynthetic valve is recommended. 6.2 Mucinous Tumor Mitral Valve 1. In patients with severe degenerative mitral regurgitation who meet the clinical indications and whose anatomic conditions permit, mitral valve repair is recommended. Patients should be seen by a surgeon experienced in valve repair. 2, Patients who have had successful mitral valve repair should receive ongoing antibiotic therapy as an indication for prevention of endocarditis. 3, Patients who have had successful mitral valve repair and have chronic or paroxysmal atrial fibrillation should receive continuous oral warfarin for long-term anticoagulation. 4, Patients who have had successful mitral valve repair should be examined for 2D and Doppler echocardiography before discharge or at the first postoperative outpatient review. 5, Patients with mitral valve disease requiring mitral valve surgery who have severe tricuspid regurgitation benefit from performing tricuspid valve repair. 6.3 Rheumatic heart disease Treatment of severe mitral stenosis should be performed by percutaneous or surgical mitral valve dissection when the anatomic situation permits and when clinically indicated. 6.4 Selection of Mitral Prosthetic Valves Patients who are unwilling or unable to take oral warfarin, or who have contraindications to warfarin therapy, have indications for mitral valve replacement with a biosynthetic valve. 6.4 Tricuspid Valve Surgery Severe tricuspid regurgitation should be corrected in surgery for multivalvular disease. VII. Intraoperative Evaluation 1. Transesophageal echocardiography is recommended for valve repair. 2, Transesophageal echocardiography is recommended in valve replacement with nonstenting allografts, homografts, or autografts. 3, Transesophageal echocardiography is recommended in surgical valve procedures for infective endocarditis. VIII. Management of Patients with Prosthetic Heart Valves 8.1 Antithrombotic Therapy 1. Any patient whose aortic valve is replaced with a mechanical valve and a Medtronic Hall valve should take oral warfarin to achieve an INR of 2.0 to 3.0 if there are no risk factors, or 2.5 to 3.5 if there are risk factors. 2. Any patient whose aortic valve is replaced with a Starr-Edwards valve or other mechanical valve ( patients with aortic valve replacement with Starr-Edwards valve or other mechanical valve (except Medtronic Hall valve), if there are no risk factors, they should take oral warfarin to achieve INR of 2.5~3.5. 3.After mitral valve replacement with any mechanical valve, they should take oral warfarin to achieve INR of 2.5~3.5. 4.Aortic and mitral valve replacement with biological valve, if there are no risk factors, they should take oral aspirin 75~100mg daily. 5.Aortic valve replacement with risk factors Patients with risk factors for aortic valve bioprosthesis should take oral warfarin to achieve an INR of 2.0 to 3.0. 6. Patients with risk factors for mitral valve bioprosthesis should take oral warfarin to achieve an INR of 2.5 to 3.5. 7. Patients who cannot tolerate warfarin therapy after mitral or aortic valve replacement should take oral aspirin 75 to 325 mg/day. 8, In addition all patients with risk factors for replacement of mechanical and biological valves of the heart, oral aspirin 75~100mg/day is recommended in addition to therapeutic doses of warfarin. 8.2 Transitional therapy for patients with mechanical valves requiring interruption of warfarin therapy for noncardiac surgery, invasive procedures, or dental procedures 1. Patients with low thrombotic risk refer to those with mechanical valve replacement of the aortic valve without risk factors. It is recommended that warfarin be discontinued 48 to 72 h before surgery (so that INR < 1.5) and restarted within 24 h after surgery. Heparin is usually not required. 2. Patients with risk factors for thrombosis, meaning patients with risk factors for mitral or aortic mechanical valve replacement, should start intravenous plain heparin after INR < 2.0 (typically 48 h before surgery), discontinue it 4 to 6 h before surgery, and resume it as soon as possible after postoperative bleeding stabilizes until INR returns to warfarin treatment levels. 8.3 Thrombosis of Prosthetic Heart Valves 1, Patients with a proposed diagnosis of prosthetic valve thrombosis are advised to use transthoracic echocardiography and Doppler echocardiography to assess hemodynamic severity. 2, Patients with a proposed diagnosis of valve thrombosis are recommended to use transesophageal echocardiography and/or radiography to assess valve mobility and thrombus load. 8.4 Follow-up 1. In the first postoperative outpatient evaluation 2 to 4 weeks after discharge of patients with prosthetic heart valves, a complete history, physical examination, and appropriate instrumentation should be established. Transthoracic Doppler echocardiography is required if an echocardiogram was not performed before discharge as a later comparison basis. 2. Patients with prosthetic heart valves should be routinely followed once a year and reevaluated (with echocardiography) as early as possible if their clinical status changes. 8.5 Follow-up of Patients With Complications Patients with left ventricular systolic insufficiency after valve surgery should receive regular medical therapy for systolic heart failure. Internal therapy should be continued even if left ventricular function has improved. 9. Evaluation and Treatment of Coronary Artery Disease in Patients with Heart Valve Disease 9.1 Diagnosis of Coronary Artery Disease 1. Patients with objective evidence of other ischemia with episodes of chest pain, reduced left ventricular systolic function, history of coronary artery disease or risk factors for coronary artery disease (including age), and indication for coronary angiography before undergoing valve surgery (including infective endocarditis) or mitral balloon angioplasty The following is a list of patients with risk factors for mitral balloon valvuloplasty Patients undergoing mitral balloon valvuloplasty do not require coronary angiography alone based on risk factors for coronary artery disease. 2. Patients with mild or moderate heart valve disease combined with progressively worsening angina (CCS3 class II), objective evidence of ischemia, reduced left ventricular systolic function, or significant congestive heart failure are indicated for coronary angiography. 3. 335-year-old male patients, 335-year-old premenopausal female patients with risk factors for coronary artery disease, and postmenopausal female patients should undergo coronary angiography prior to valve surgery. 9.2 Treatment of Coronary Artery Disease at the Time of Aortic Valve Replacement Patients undergoing aortic valve replacement who have severe stenosis (≥70% lumen diameter loss) in a large coronary artery should undergo surgical coronary artery bypass grafting. 9.3 Aortic valve replacement in patients undergoing surgical coronary artery bypass grafting Patients with severe aortic stenosis who are eligible for valve replacement have indications for aortic valve replacement when undergoing surgical coronary artery bypass grafting.