2017ESC心脏瓣膜病指南

2017ESC/EACTSGuidelinesforthemanagementofvalvularheartdiseaseTheTaskForcefortheManagementofValvularHeartDiseaseoftheEuropeanSocietyofCardiology(ESC)andtheEuropeanAssociationforCardio-ThoracicSurgery(EACTS)Authors/TaskForceMembers:HelmutBaumgartner*(ESCChairperson)(Germany),VolkmarFalk*1(EACTSChairperson)(Germany),JeroenJ.Bax(TheNetherlands),MicheleDeBonis1(Italy),ChristianHamm(Germany),PerJohanHolm(Sweden),BernardIung(France),PatrizioLancellotti(Belgium),EmmanuelLansac1(France),DanielRodriguezMu~noz(Spain),RaphaelRosenhek(Austria),JohanSjögren1(Sweden),PilarTornosMas(Spain),AlecVahanian(France),ThomasWalther1(Germany),OlafWendler1(UK),StephanWindecker(Switzerland),JoseLuisZamorano(Spain)DocumentReviewers:MarcoRoffi(CPGReviewCoordinator)(Switzerland),OttavioAlfieri1(EACTSReviewCoordinator)(Italy),StefanAgewall(Norway),AndersAhlsson1(Sweden),EmanueleBarbato(Italy),HéctorBueno(Spain),Jean-PhilippeCollet(France),IoanMirceaComan(Romania),MartinCzerny(Germany),VictoriaDelgado(TheNetherlands),DonnaFitzsimons(UK),ThierryFolliguet1(France),OliverGaemperli(Switzerland),GilbertHabib(France),WolfgangHarringer1(Germany),MichaelHaude*Correspondingauthors:HelmutBaumgartner,DivisionofAdultCongenitalandValvularHeartDisease,DepartmentofCardiovascularMedicine,UniversityHospitalMuenster,AlbertSchweitzerCampus1,BuildingA1,48149Muenster,Germany.Tel:þ492518346110,Fax:þ492518346109,E-mail:helmut.baumgartner@ukmuenster.de.VolkmarFalk,DepartmentofCardiothoracicandVascularSurgery,GermanHeartCenter,AugustenburgerPlatz1,D-133353Berlin,GermanyandDepartmentofCardiovascularSurgery,ChariteBerlin,Chariteplatz1,D-10117Berlin,Germany.Tel:þ493045932000,Fax:þ493045932100,E-mail:falk@dhzb.de.ESCCommitteeforPracticeGuidelines(CPG)andNationalCardiacSocietiesdocumentreviewerslistedintheAppendix.1RepresentingtheEuropeanAssociationforCardio-ThoracicSurgery(EACTS).ESCentitieshavingparticipatedinthedevelopmentofthisdocument:Associations:AcuteCardiovascularCareAssociation(ACCA),EuropeanAssociationofCardiovascularImaging(EACVI),EuropeanAssociationofPercutaneousCardiovascularInterventions(EAPCI),HeartFailureAssociation(HFA).WorkingGroups:CardiovascularPharmacotherapy,CardiovascularSurgery,Grown-upCongenitalHeartDisease,ValvularHeartDisease.ThecontentoftheseEuropeanSocietyofCardiology(ESC)Guidelineshasbeenpublishedforpersonalandeducationaluseonly.Nocommercialuseisauthorized.NopartoftheESCGuidelinesmaybetranslatedorreproducedinanyformwithoutwrittenpermissionfromtheESC.PermissioncanbeobtaineduponsubmissionofawrittenrequesttoOxfordUniversityPress,thepublisheroftheEuropeanHeartJournalandthepartyauthorizedtohandlesuchpermissionsonbehalfoftheESC(journals.permissions@oxfordjournals.org).Disclaimer.TheESCGuidelinesrepresenttheviewsoftheESCandwereproducedaftercarefulconsiderationofthescientificandmedicalknowledgeandtheevidenceavailableatthetimeoftheirpublication.TheESCisnotresponsibleintheeventofanycontradiction,discrepancyand/orambiguitybetweentheESCGuidelinesandanyotherofficialrecom-mendationsorguidelinesissuedbytherelevantpublichealthauthorities,inparticularinrelationtogooduseofhealthcareortherapeuticstrategies.Healthprofessionalsareencour-agedtotaketheESCGuidelinesfullyintoaccountwhenexercisingtheirclinicaljudgment,aswellasinthedeterminationandtheimplementationofpreventive,diagnosticortherapeuticmedicalstrategies;however,theESCGuidelinesdonotoverride,inanywaywhatsoever,theindividualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofeachpatient’shealthconditionandinconsultationwiththatpatientand,whereappropriateand/ornecessary,thepatient’scaregiver.NordotheESCGuidelinesexempthealthprofessionalsfromtakingintofullandcarefulconsiderationtherelevantofficialupdatedrecommendationsorguidelinesissuedbythecompetentpublichealthauthoritiesinordertomanageeachpatientscaseinlightofthescientificallyaccepteddatapursuanttotheirrespectiveethicalandprofessionalobligations.Itisalsothehealthprofessional’sresponsibilitytoverifytheapplicablerulesandregulationsrelatingtodrugsandmedicaldevicesatthetimeofprescription.Thearticlehasbeenco-publishedwithpermissionintheEuropeanHeartJournal[10.1093/eurheartj/ehx391]onbehalfoftheEuropeanSocietyofCardiologyandEuropeanJournalofCardio-ThoracicSurgery[10.1093/ejcts/ezx324]onbehalfoftheEuropeanAssociationforCardio-ThoracicSurgery.AllrightsreservedinrespectofEuropeanHeartJournal,VCEuropeanSocietyofCardiology2017.Thearticlesareidenticalexceptforminorstylisticandspellingdifferencesinkeepingwitheachjournal’sstyle.Eithercitationcanbeusedwhencitingthisarticle.Forpermissions,pleaseemailjournals.permissions@oup.com.EuropeanHeartJournal(2017)38,2739–2786ESC/EACTSGUIDELINESdoi:10.1093/eurheartj/ehx391Downloadedfromhttps://academic.oup.com/eurheartj/article-abstract/38/36/2739/4095039bygueston25November2017..........................................................................................................(Germany),GerhardHindricks(Germany),HugoA.Katus(Germany),JuhaniKnuuti(Finland),PhilippeKolh(Belgium),ChristopheLeclercq(France),TheresaA.McDonagh(UK),MassimoFrancescoPiepoli(Italy),LucA.Pierard(Belgium),PiotrPonikowski(Poland),GiuseppeM.C.Rosano(UK/Italy),FrankRuschitzka(Switzerland),EvgenyShlyakhto(RussianFederation),IainA.Simpson(UK),MiguelSousa-Uva1(Portugal),JaninaStepinska(Poland),GiuseppeTarantini(Italy),DidierTchétché(France),VictorAboyans(CPGSupervisor)(France)ThedisclosureformsofallexpertsinvolvedinthedevelopmentoftheseguidelinesareavailableontheESCwebsitehttp://www.escardio.org/guidelines.FortheWebAddendawhichincludebackgroundinformationanddetaileddiscussionofthedatathathaveprovidedthebasisfortherecommendationsseehttps://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehx391#supplementary-data.Onlinepublish-ahead-of-print26August2017...................................................................................................................................................................................................KeywordsGuidelines•Valvedisease•Valvesurgery•Percutaneousvalveintervention•Aorticregurgitation•Aorticstenosis•Mitralregurgitation•Mitralstenosis•Tricuspidregurgitation•Tricuspidstenosis•ProstheticheartvalvesTableofContentsAbbreviationsandacronyms......................................27411.Preamble......................................................27412.Introduction...................................................27432.1Whydoweneednewguidelinesonvalvularheartdisease?..27432.2Contentoftheseguidelines.................................27432.3Newformatoftheguidelines...............................27432.4Howtousetheseguidelines................................27433.Generalcomments............................................27433.1Patientevaluation..........................................27433.1.1Echocardiography......................................27443.1.2Othernon-invasiveinvestigations.......................27443.1.2.1Stresstesting.......................................27443.1.2.2Cardiacmagneticresonance..........................27453.1.2.3Computedtomography..............................27453.1.2.4Cinefluoroscopy.....................................27453.1.2.5Biomarkers.........................................27453.1.3Invasiveinvestigations..................................27453.1.3.1Coronaryangiography...............................27453.1.3.2Cardiaccatheterization..............................27463.1.4Assessmentofcomorbidity.............................27463.2Riskstratification...........................................27463.3Specialconsiderationsinelderlypatients....................27463.4Endocarditisprophylaxis....................................27463.5Prophylaxisforrheumaticfever.............................27463.6ConceptoftheHeartTeamandheartvalvecentres.........27463.7Managementofassociatedconditions.......................27473.7.1Coronaryarterydisease................................27473.7.2Atrialfibrillation........................................27474.Aorticregurgitation............................................27484.1Evaluation..................................................27484.1.1Echocardiography......................................27484.1.2Computedtomographyandcardiacmagneticresonance.27494.2Indicationsforintervention.................................27494.3Medicaltherapy............................................27514.4Serialtesting...............................................27514.5Specialpatientpopulations.................................27515.Aorticstenosis.................................................27515.1Evaluation..................................................27515.1.1Echocardiography......................................27515.1.2Additionaldiagnosticaspects,includingassessmentofprognosticparameters......................................27535.1.3Diagnosticworkupbeforetranscatheteraorticvalveimplantation..27535.2Indicationsforintervention.................................27545.2.1Indicationsforinterventioninsymptomaticaorticstenosis.27565.2.2Choiceofinterventionmodeinsymptomaticaorticstenosis.....................................................27565.2.3Asymptomaticaorticstenosis...........................27565.3Medicaltherapy............................................27575.4Serialtesting...............................................27575.5Specialpatientpopulations.................................27586.Mitralregurgitation............................................27586.1Primarymitralregurgitation.................................27586.1.1Evaluation.............................................27586.1.2Indicationsforintervention.............................27606.1.3Medicaltherapy........................................27616.1.4Serialtesting...........................................27616.2Secondarymitralregurgitation..............................27616.2.1Evaluation.............................................27616.2.2Indicationsforintervention.............................27616.2.3Medicaltherapy........................................27627.Mitralstenosis.................................................27627.1Evaluation..................................................27627.2Indicationsforintervention.................................27647.3Medicaltherapy............................................27647.4Serialtesting...............................................27657.5Specialpatientpopulations.................................27668.Tricuspidregurgitation.........................................27668.1Evaluation..................................................27662740ESC/EACTSGuidelinesDownloadedfromhttps://academic.oup.com/eurheartj/article-abstract/38/36/2739/4095039bygueston25November2017............................................................................................................................................................................8.2Indicationsforintervention.................................27669.Tricuspidstenosis..............................................27689.1Evaluation..................................................27689.2Indicationsforintervention.................................27689.3Medicaltherapy............................................276810.Combinedandmultiplevalvediseases.........................276911.Prostheticvalves..............................................276911.1Choiceofprostheticvalve.................................276911.2Managementaftervalveintervention.......................277011.2.1Baselineassessmentandmodalitiesoffollow-up........277011.2.2Antithromboticmanagement..........................277111.2.2.1Generalmanagement..............................277111.2.2.2Targetinternationalnormalizedratio.................277111.2.2.3ManagementofvitaminKantagonistoverdoseandbleeding...............................................277111.2.2.4Combinationoforalanticoagulantswithantiplateletdrugs.....................................................277311.2.2.5Interruptionofanticoagulanttherapyforplannedinvasiveprocedures.........................................277411.2.3Managementofvalvethrombosis......................277411.2.4Managementofthromboembolism....................277711.2.5Managementofhaemolysisandparavalvularleak.......277711.2.6Managementofbioprostheticvalvefailure.............277711.2.7Heartfailure..........................................277712.Managementduringnon-cardiacsurgery.......................277712.1Preoperativeevaluation...................................277712.2Specificvalvelesions......................................277812.2.1Aorticstenosis.......................................277812.2.2Mitralstenosis........................................277812.2.3Aorticandmitralregurgitation........................277812.3Perioperativemonitoring..................................277913.Managementduringpregnancy................................277913.1Nativevalvedisease.......................................277913.2Prostheticvalves..........................................277914.TodoandnottodomessagesfromtheGuidelines.............278015.Whatisnewinthe2017ValvularHeartDiseaseGuidelines?....278216.Appendix....................................................278417.References...................................................2785AbbreviationsandacronymsDPmMeantransvalvularpressuregradient2DTwo-dimensional3DThree-dimensionalABCAge,biomarkers,clinicalhistoryACEAngiotensin-convertingenzymeACSAcutecoronarysyndromeARBAngiotensinreceptorblockerAVAAorticvalveareaBAVBalloonaorticvalvuloplastyBNPB-typenatriureticpeptideBSABodysurfaceareaCABGCoronaryarterybypassgraftingCADCoronaryarterydiseaseCIContra-indication(s)CMRCardiovascularmagneticresonanceCPGCommitteeforPracticeGuidelinescardiacresynchronizationtherapyCTComputedtomographyEACTSEuropeanAssociationforCardio-ThoracicSurgeryECGElectrocardiogramEDVEnd-diastolicvelocityEROAEffectiveregurgitantorificeareaESCEuropeanSocietyofCardiologyEuroSCOREEuropeanSystemforCardiacOperativeRiskEvaluationINRInternationalnormalizedratioIVIntravenousLALeftatrium/leftatrialLMWHLow-molecular-weightheparinLVLeftventricle/leftventricularLVEDDLeftventricularend-diastolicdiameterLVEFLeftventricularejectionfractionLVESDLeftventricularend-systolicdiameterLVOTLeftventricularoutflowtractMSCTMultislicecomputedtomographyNOACNon-vitaminKantagonistoralanticoagulantNYHANewYorkHeartAssociationPCIPercutaneouscoronaryinterventionPISAProximalisovelocitysurfaceareaPMCPercutaneousmitralcommissurotomyRVRightventricle/rightventricularSAVRSurgicalaorticvalvereplacementSPAPSystolicpulmonaryarterialpressureSTSSocietyofThoracicSurgeonsSViStrokevolumeindexTAVITranscatheteraorticvalveimplantationTOETransoesophagealechocardiographyTTETransthoracicechocardiographyTVITime–velocityintervalUFHUnfractionatedheparinVHDValvularheartdiseaseVKAVitaminKantagonistVmaxPeaktransvalvularvelocity1.PreambleGuidelinessummarizeandevaluateavailableevidencewiththeaimofassistinghealthprofessionalsinselectingthebestmanagementstrat-egiesforanindividualpatientwithagivencondition.Guidelinesandtheirrecommendationsshouldfacilitatedecisionmakingofhealthpro-fessionalsintheirdailypractice.However,thefinaldecisionsconcerninganindividualpatientmustbemadebytheresponsiblehealthprofessio-nal(s)inconsultationwiththepatientandcaregiverasappropriate.AgreatnumberofguidelineshavebeenissuedinrecentyearsbytheEuropeanSocietyofCardiology(ESC)andbytheEuropeanAssociationforCardio-ThoracicSurgery(EACTS)aswellasbyothersocietiesandorganisations.Becauseoftheimpactonclinicalpractice,qualitycriteriaforthedevelopmentofguidelineshavebeenestablishedinordertomakealldecisionstransparenttotheuser.TherecommendationsforformulatingandissuingESCGuidelinescanbefoundontheESCESC/EACTSGuidelines2741Downloadedfromhttps://academic.oup.com/eurheartj/article-abstract/38/36/2739/4095039bygueston25November2017..................................................website(https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines).ESCGuide-linesrepresenttheofficialpositionoftheESConagiventopicandareregularlyupdated.MembersofthisTaskForcewereselectedbytheESCandEACTStorepresentprofessionalsinvolvedwiththemedicalcareofpatientswiththispathology.Selectedexpertsinthefieldundertookacom-prehensivereviewofthepublishedevidenceformanagementofagivenconditionaccordingtoESCCommitteeforPracticeGuidelines(CPG)policyandapprovedbytheEACTS.Acriticalevaluationofdiagnosticandtherapeuticprocedureswasperformed,includingassessmentoftherisk–benefitratio.Thelevelofevidenceandthestrengthoftherecommendationofparticularmanagementoptionswereweighedandgradedaccordingtopredefinedscales,asoutlinedinTables1and2.Theexpertsofthewritingandreviewingpanelsprovideddeclara-tionofinterestformsforallrelationshipsthatmightbeperceivedasrealorpotentialsourcesofconflictsofinterest.TheseformswerecompiledintoonefileandcanbefoundontheESCwebsite(http://www.escardio.org/guidelines).AnychangesindeclarationsofinterestthatariseduringthewritingperiodwerenotifiedtotheESCandEACTSandupdated.TheTaskForcereceiveditsentirefinancialsup-portfromtheESCandEACTSwithoutanyinvolvementfromthehealthcareindustry.TheESCCPGsupervisesandcoordinatesthepreparationofnewGuidelines.TheCommitteeisalsoresponsiblefortheendorsementprocessoftheseGuidelines.TheESCGuidelinesundergoextensivereviewbytheCPGandexternalexperts,andinthiscasebyEACTS-appointedexperts.AfterappropriaterevisionstheGuidelinesareapprovedbyalltheexpertsinvolvedintheTaskForce.ThefinalizeddocumentisapprovedbytheCPGandEACTSforpublicationintheEuropeanHeartJournalandintheEuropeanJournalofCardio-ThoracicSurgery.TheGuidelinesweredevelopedaftercare-fulconsiderationofthescientificandmedicalknowledgeandtheevi-denceavailableatthetimeoftheirdating.ThetaskofdevelopingESC/EACTSGuidelinesalsoincludesthecreationofeducationaltoolsandimplementationprogrammesfortherecommendationsincludingcondensedpocketguidelinever-sions,summaryslides,bookletswithessentialmessages,summarycardsfornon-specialistsandanelectronicversionfordigitalapplica-tions(smartphones,etc.).Theseversionsareabridgedandthus,ifneeded,oneshouldalwaysrefertothefulltextversion,whichisfreelyavailableviatheESCwebsiteandhostedontheEHJwebsite.TheNationalSocietiesoftheESCareencouragedtoendorse,trans-lateandimplementallESCGuidelines.Implementationprogrammesareneededbecauseithasbeenshownthattheoutcomeofdiseasemaybefavourablyinfluencedbythethoroughapplicationofclinicalrecommendations.Table1ClassesofrecommendationsTable2LevelsofevidenceLevelofevidenceADataderivedfrommultiplerandomizedclinicaltrialsormeta-analyses.LevelofevidenceBDataderivedfromasinglerandomizedclinicaltrialorlargenon-randomizedstudies.LevelofevidenceCConsensusofopinionoftheexpertsand/orsmallstudies,retrospectivestudies,registries.©ESC20172742ESC/EACTSGuidelinesDownloadedfromhttps://academic.oup.com/eurheartj/article-abstract/38/36/2739/4095039bygueston25November2017......................................................................................Surveysandregistriesareneededtoverifythatreal-lifedailyprac-ticeisinkeepingwithwhatisrecommendedintheguidelines,thuscompletingtheloopbetweenclinicalresearch,writingofguidelines,disseminatingthemandimplementingthemintoclinicalpractice.HealthprofessionalsareencouragedtotaketheESC/EACTSGuidelinesfullyintoaccountwhenexercisingtheirclinicaljudgment,aswellasinthedeterminationandtheimplementationofpreventive,diagnosticortherapeuticmedicalstrategies.However,theESC/EACTSGuidelinesdonotoverrideinanywaywhatsoevertheindi-vidualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofeachpatient’shealthconditionandinconsultationwiththatpatientorthepatient’scaregiverwhereappropriateand/ornecessary.Itisalsothehealthprofessional’sresponsibilitytoverifytherulesandregulationsapplicabletodrugsanddevicesatthetimeofprescription.2.Introduction2.1.Whydoweneednewguidelinesonvalvularheartdisease?Sincethepreviousversionoftheguidelinesonthemanagement