ESC瓣膜性心脏病管理指南

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2023 ESC心内膜炎管理指南更新要点

2023 ESC心内膜炎管理指南更新要点新增建议1.对接受牙科手术且感染性心内膜炎（IE）风险增加的心血管疾病患者进行预防性抗生素治疗➤对于IE高危和中危人群，建议采取一般预防措施。

（I，C）➤建议使用心室辅助装置的患者预防性使用抗生素。

（I，C）➤心脏移植受者可考虑预防性使用抗生素。

（IIb，C）2.高危患者IE预防建议➤对于接受呼吸系统、胃肠系统、泌尿生殖系统、皮肤或肌肉骨骼系统侵入性诊断或治疗手术的高危患者，可考虑进行全身抗生素预防。

（IIb，C）3.心脏手术中IE预防建议➤建议对植入部位采取最佳的术前无菌措施，以预防心血管植入式电子装置（CIED）感染。

（I，B）➤在导管室环境下进行导管插入和操作时，建议采取标准的外科无菌措施。

（I，C）➤在经导管主动脉瓣置换术（TAVI）和其他经导管瓣膜手术之前，应考虑对常见的皮肤菌群（包括肠球菌和金黄色葡萄球菌）进行抗生素预防。

（IIa，C）4.超声心动图在IE中的作应用建议➤在患者病情稳定后，建议在由抗生素静脉给药转为口服治疗之前进行经食管超声心动图（TOE）。

（I，B）5.关于CT、核成像和磁共振在IE中的应用建议➤对于可能存在自体瓣膜心内膜炎（NVE）的患者，推荐行心脏计算机断层扫描血管造影（CTA）检查，以发现瓣膜病变，明确IE诊断。

（I，B）➤对于可能发生人工瓣膜心内膜炎（PVE）的患者，推荐行¹⁸F-氟脱氧葡萄糖正电子发射计算机断层扫描（[18F]FDG-PET）/CT(A)和心脏CTA检查，以发现瓣膜病变，明确IE诊断。

（I，B）➤对于可能的CIED相关IE，可考虑[18F]FDG-PET/CT(A)以明确IE诊断。

（IIa，B）➤对于超声心动图不能明确诊断，推荐在NVE和PVE中进行心脏CTA检查来诊断瓣膜旁或假体周围并发症。

（I，B）➤对于有症状的NVE和PVE患者，建议进行脑和全身影像学检查（CT、[18F]FDG-PET/ CT和/或磁共振[MRI]），以检查外周病变或增加次要诊断标准。

心脏瓣膜病管理指南中文

心脏瓣膜病管理指南中文心脏瓣膜病是一种影响心脏瓣膜功能的疾病，严重影响患者的生活质量和健康。

为了更好地管理和治疗心脏瓣膜病，医学界制定了心脏瓣膜病管理指南。

本文将详细介绍心脏瓣膜病管理指南的主要内容。

一、概述心脏瓣膜病是指心脏瓣膜发生结构或功能异常，导致血液流动受阻或逆流的疾病。

常见的心脏瓣膜病有二尖瓣狭窄、二尖瓣关闭不全、主动脉瓣狭窄和主动脉瓣关闭不全等。

二、诊断标准心脏瓣膜病的诊断主要依靠临床症状、体格检查和影像学检查。

临床症状包括心悸、气促、乏力等，体格检查可发现心脏杂音和心脏扩大。

影像学检查可以通过超声心动图、心导管检查等明确诊断。

三、治疗原则心脏瓣膜病的治疗原则包括保持心脏稳定、缓解症状、预防并发症和改善生活质量。

具体治疗方法根据病情和病因而定，包括药物治疗、手术治疗和介入治疗等。

四、药物治疗药物治疗是心脏瓣膜病的基础治疗方法，可以通过药物控制心率、降低血压、改善心脏功能等。

常用的药物包括β受体阻滞剂、洋地黄类药物、利尿剂等。

五、手术治疗手术治疗是治疗心脏瓣膜病的最有效方法之一，主要适用于瓣膜狭窄或关闭不全严重的患者。

常见的手术方法包括瓣膜置换术、瓣膜修复术等。

六、介入治疗介入治疗也是治疗心脏瓣膜病的一种方法，适用于部分病情较轻或高危手术患者。

常见的介入治疗包括瓣膜扩张术、瓣膜置换术等。

七、术后护理心脏瓣膜病手术后的护理非常重要，包括术后监测、抗凝治疗、抗感染治疗等。

此外，患者还需要定期复查和康复训练，以提高康复效果。

八、预防与控制心脏瓣膜病的预防与控制主要包括积极治疗心脏病、注意生活方式、定期体检等。

尤其对于患有风湿性心脏病的人群，预防风湿热的发生非常重要。

九、遵循管理指南心脏瓣膜病管理指南是医学界对心脏瓣膜病治疗的权威指南，患者和医生都应该遵循指南进行治疗。

同时，管理指南也会根据研究进展和临床实践进行更新和修订。

结语心脏瓣膜病是一种常见的心血管疾病，对患者的生活和健康造成很大影响。

ESC瓣膜性心脏病管理指南(最全版)

ESC瓣膜性心脏病管理指南（最全版）——欧洲心脏学会（ESC）和欧洲心胸外科协会（EACTS）瓣膜性心脏病管理联合工作组目录表缩略语1.前言2.介绍2．1．我们为什么需要新的瓣膜性心脏病指南？2．2．这些指南的内容2．3．如何使用这些指南3．总体情况述评3．1．患者评估3．1．1．临床评估3．1．2．超声心动图3．1．3．其它非侵入性检查3．1．3．1．负荷试验3．1．3．2．心脏磁共振（CMR）3．1．3．3．计算机断层摄影3．1．3．4．荧光镜检查3．1．3．5．放射核素血管造影3．1．3．6．生物标志物3．1．4．侵入性检查3．1．5．合并症的评估3．2．心内膜炎的预防3．3．风湿热的预防3．4．危险分层3．5．相关情况的管理3．5．1．冠心病3．5．2．心律失常4．主动脉反流4．1．评估4．2．自然史4．3．手术结果4．4．手术适应症4．5．药物治疗4．6．连续检测4．7．特殊患者人群5．主动脉狭窄5．1．评估5．2．自然史5．3．介入治疗结果5．4．介入治疗的适应症5．4．1．主动脉瓣膜置换的适应症5．4．2．球囊瓣膜成形术的适应症5．4．3．经导管主动脉瓣置入的适应症5．5．药物治疗5．6．系列检测5．7．特殊患者人群6．二尖瓣反流6．1．原发性二尖瓣反流6．1．1．评估6．1．2．自然史6．1．3．手术结果6．1．4．经皮介入治疗6．1．5．介入治疗的适应症6．1．6．药物治疗6．1．7．系列检测6．2．继发性二尖瓣反流6．2．1．评估6．2．2．自然史6．2．3．手术结果6．2．4．经皮介入治疗6．2．5．介入治疗的适应症6．2．6．药物治疗7．二尖瓣狭窄7．1．评估7．2．自然史7．3．介入治疗的结果7．3．1．经皮二尖瓣连合部切开术7．3．2．手术7．4．介入治疗的适应症7．5．药物治疗7．6．系列检测7．7．特殊患者人群8．三尖瓣反流8．1．评估8．2．自然史8．3．手术结果8．4．手术适应症8．5．药物治疗9．三尖瓣狭窄9．1．评估9．2．手术9．3．经皮介入治疗9．4．介入治疗的适应症9．5．药物治疗10．联合瓣膜和多瓣膜病变11．人工瓣膜11．1．人工瓣膜的选择11．2．瓣膜置换后的管理11.2.1.基线评估和随访模式11. 2.2.抗栓治疗11.2.2..1.一般治疗11.2.2.2.目标INR11.2.2.3.维生素K拮抗剂过量和出血的处理11.2.2.4.口服抗凝剂与抗血小板药的联用11.2.2.5. 抗凝治疗的中断11.2.3.瓣膜血栓形成的处理11.2.4.血栓栓塞的处理11.2.5.溶血和瓣周漏的处理11.2.6.生物人工瓣膜失效的处理11.2.7.心力衰竭12.非心脏手术期间的管理12.1.围术期评估12.2.特殊瓣膜病变12.2.1.主动脉狭窄12.2.2.二尖瓣狭窄12.2.3.主动脉瓣和二尖瓣反流12.2.4.人工瓣膜12.3.围术期监测13.妊娠期间的管理13.1.自然瓣膜病变13.2.人工瓣膜病变参考文献缩略语ACE 血管紧张素转换酶AF 心房颤动aPTT活化部分凝血活酶时间AR 主动脉瓣反流ARB 血管紧张素受体抑制剂AS 主动脉狭窄AVB 主动脉瓣置换BNP B-型利钠肽BSA 体面面积CABG 冠状动脉旁路移植CAD 冠心病CMR 心脏磁共振CPG 实践指南委员会CRT 心脏再同步化治疗CT 计算机断层摄影EACTS 欧洲心胸外科医师协会ECG 心电图EF 射血分数EROA 有效反流口面积ESC 欧洲心脏学会EVEREST（血管内瓣膜边缘对边缘修复研究）HF 心力衰竭INR国际标准化比率LA 左房LMWH 低分子量肝素LV 左室LVEF 左室射血分数LVEDD 左室舒张末内径LVSED 左室收缩末内径MR 二尖瓣反流MS 二尖瓣狭窄MSCT 多层计算机断层摄影NYHA 纽约心脏协会PISA 近段等速线表面积PMC 经皮二尖瓣连合部切开术PVL 瓣周漏RV 右室r-tPA 重组组织型纤溶酶原激活物SVD 结构性瓣膜退化STS 美国胸外科医师协会TAPSE 三尖瓣环平面收缩偏移TAVI 经导管主动脉瓣植入术TEE 经食管超声心动图TR 三尖瓣反流TS 三尖瓣狭窄TTE 经胸超声心动图UFH 普通肝素VHD 瓣膜性心脏病3DE 3维超声心动图1.前言在指南的编写过程中，对一个指定的问题，编委们总结和评价了所有可用的证据，旨在帮助医师对有特定情况的每个患者，考虑对预后的影响以及特殊诊断或治疗方法的风险-获益比，选择最佳的处理对策。

ESC重磅解读丨吴永健教授：《2021ESCEACTS心脏瓣膜病管理指南》更新

ESC重磅解读⼁吴永健教授：《2021ESCEACTS⼼脏瓣膜病管理指南》更新《2021 ESC/EACTS⼼脏瓣膜病管理指南》在2021年欧洲⼼脏病学年会（ESC 2021）期间重磅发布，完成了对2017年指南的重要更新。

随着近年来⼼脏瓣膜病治疗⼤规模研究数据的循证医学证据及临床经验的积累，本版指南基于2017版本在整体治疗策略评估、瓣膜病治疗⽅式尤其是经导管治疗适应证拓展、新技术和新器械研发以及围术期药物管理等⽅⾯进⾏了切实的调整与更新，对当下及未来的⼼脏瓣膜病临床实践⼯作具有巨⼤的指导意义。

在此，我团队谨对本版指南重要更新内容做⼀系统总结并解读，与⼴⼤读者⼀起学习。

1瓣膜病患者的评估、风险分层及联合⼿术策略新版指南仍强调医疗协同体、瓣膜病中⼼、瓣膜病门诊对瓣膜性⼼脏病（VHD患者）进⾏以患者为中⼼的协同评估，且对VHD患者的评估做了更加详细系统的定义，主要包括两⼤部分：1.临床及影像评估；2.⼼脏团队评估。

在VHD患者危险分层⽅⾯，仍强调STS-PROM评分和EuroSCORE II，在外科⼿术中具有较⾼的风险预测价值，但指出其可能并不适⽤于接受经导管治疗的患者。

新版指南增加了对于患者⾃⾝预期⼿术效果、⽣活质量、症状缓解程度的评估，强调应重视患者及家属在治疗决策中的参与，从患者及家属的预期⾓度评估⼿术效果。

增加了对于患者衰弱状况、营养不良和认知损害、器官功能损害、解剖相关因素等的评估。

强调医疗机构应结合⾃⾝优势领域、技术成熟程度等因素为患者选择最合适的治疗⽅式。

在合并房颤的患者的处理中，基于近年来多个RCT研究的亚组分析显⽰利伐沙班、阿哌沙班、达⽐加群等在瓣膜病（如AR、AS、MR）患者中预防卒中及栓塞事件风险⽅⾯不劣于华法林，新版指南推荐对此类患者应优选新型⼝服抗凝药（NOACs），⽽不是维⽣素K拮抗剂（VKAs）类药物来进⾏抗凝治疗（I，A）。

基于LAAOS III研究，应⽤左⼼⽿封堵术（LAAO）组患者相⽐对照组卒中和系统性栓塞事件发⽣风险降低了33%，为LAAO预防栓塞风险应⽤提供了强有⼒的证据⽀持，新指南认为在CHA2DS2-VASc评分≥2分的患者，接受瓣膜⼿术治疗时应考虑进⾏左⼼⽿夹闭术以减少⾎栓栓塞风险 (IIa，B)（2017年指南认为瓣膜病合并房颤患者在接受外科⼿术治疗时可以考虑进⾏左⼼⽿切除或夹闭（IIb，C））。

ESC 2023心脏手术最新技术指南(全文)

ESC 2023心脏手术最新技术指南(全文)前言欧洲心脏病学会（ESC）荣幸地发布2023心脏手术最新技术指南，以推动全球心血管病治疗技术的进步。

本指南基于最新的科学研究和临床实践，为心脏手术提供了全面、权威的指导。

我们诚挚地邀请心血管领域专业人士参考和应用本指南，以提高手术治疗效果，改善患者生活质量。

目录1. 引言2. 心脏手术概述3. 心脏手术技术3.1 冠状动脉旁路移植术3.2 心脏起搏器和ICD植入术3.3 心脏瓣膜置换术3.4 先天性心脏病手术3.5 心脏肿瘤手术4. 围手术期管理4.1 术前评估与准备4.2 术中监护与管理4.3 术后康复与随访5. 特殊人群心脏手术5.1 老年患者心脏手术5.2 儿童与青少年心脏手术5.3 孕妇心脏手术6. 创新技术与未来趋势7. 实践建议与结论引言随着心血管疾病诊疗技术的不断发展，心脏手术在治疗严重心脏疾病中发挥着举足轻重的作用。

ESC 2023心脏手术最新技术指南旨在为全球心血管专业人士提供最新的手术技术、围手术期管理和特殊人群手术处理的指导意见。

心脏手术概述心脏手术是指通过外科手术方法对心脏进行治疗和修复的过程。

心脏手术可治疗多种严重心脏疾病，如冠状动脉疾病、心脏瓣膜病变、先天性心脏病、心脏肿瘤等。

手术治疗可显著改善患者症状、提高生活质量，甚至挽救生命。

心脏手术技术3.1 冠状动脉旁路移植术冠状动脉旁路移植术（CABG）是治疗冠状动脉粥样硬化性心脏病的主要手术方法。

手术通过在主动脉和冠状动脉之间建立旁路，使血液绕过狭窄的冠状动脉，到达心脏供血。

本指南推荐使用桡动脉、左乳内动脉等作为旁路血管来源，以提高手术成功率。

3.2 心脏起搏器和ICD植入术心脏起搏器和植入式心脏除颤器（ICD）用于治疗心律失常。

本指南建议在充分评估患者心律失常类型和风险后，选择合适的起搏器和ICD。

术中应确保电极导线正确植入，以保证患者生命安全。

3.3 心脏瓣膜置换术心脏瓣膜置换术用于治疗严重瓣膜病变，如风湿性心脏病、老年性瓣膜病变等。

ESC2017│7点思考，写在欧洲心脏瓣膜病指南发布前

ESC2017│7点思考，写在欧洲心脏瓣膜病指南发布前欧洲心脏病学会（ESC）2017年会将于8 月26-30 日在西班牙巴塞罗那隆重召开。

届时，ESC和欧洲心胸协会（EACTS）将联合推出“心脏瓣膜疾病指南更新”（前一版发布于2012年）。

就在今年3月15日，美国心脏协会（AHA）和美国心脏病学会（ACC）也重点更新了2014年发布的心脏瓣膜病指南。

欧美指南将有哪些异同，我们拭目以待。

ESC会前，本报记者特邀美国新泽西州大西洋城医学中心郑景生医生和美国圣路易斯华盛顿大学/退伍军人医院欧加福医生带领我们回顾2017美国瓣膜病指南的重要建议，并预测欧洲指南可能的更新亮点。

作者：美国新泽西州大西洋城医学中心郑景生，美国圣路易斯华盛顿大学/退伍军人医院欧加福（利益冲突声明：本文与任何制药厂家没有任何关系）2017美国瓣膜病指南10大更新点2017美国瓣膜病指南重点对以下几种疾病做了修改或提了新的建议：对感染性心内膜炎的预防性使用抗生素的适应证，房颤患者使用新型口服抗凝药（DOACs）, 经导管主动脉瓣置换术（TAVR）的适应证，原发性和继发性二尖瓣反流的外科治疗和人工心脏瓣膜的选择及处理。

关键建议总结如下：1. 感染性心内膜炎的预防患者如果有经导管瓣膜置换，或者用于瓣膜修复的假体材料（包括瓣环或人工键索），建议牙科手术前进行抗生素预防（Class IIa, 证据等级[LOE] C-LD)。

2. 心房颤动的抗凝治疗a. 风湿性二尖瓣狭窄合并心房颤动的患者，仍然应用维生素K 拮抗剂抗凝(Class I, LOE B-NR).。

b. 自体主动脉瓣疾病、三尖瓣疾病或二尖瓣关闭不全合并心房颤动的患者，如果CHA2DS2 VASc 得分≥2 应使用抗凝治疗(Class I, LOE C-LD).)。

c. 自体主动脉瓣疾病、三尖瓣疾病或二尖瓣关闭不全合并心房颤动的患者，如果CHA2DS2 VASc 得分≥2 使用新型口服抗凝药（DOACs）代替维生素K 拮抗剂（VKA）是个合理的选择(Class IIa, LOE C-LD)。

2012ESC+心脏瓣膜病管理指南

医脉通w w w .m e d l i v e.c n ESC/EACTS GUIDELINESGuidelines on the management of valvular heart disease (version 2012)The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC)and the European Association for Cardio-Thoracic Surgery (EACTS)Authors/Task Force Members:Alec Vahanian (Chairperson)(France)*,Ottavio Alﬁeri (Chairperson)*(Italy),Felicita Andreotti (Italy),Manuel J.Antunes (Portugal),Gonzalo Baro ´n-Esquivias (Spain),Helmut Baumgartner (Germany),Michael Andrew Borger (Germany),Thierry P.Carrel (Switzerland),Michele De Bonis (Italy),Arturo Evangelista (Spain),Volkmar Falk (Switzerland),Bernard Iung(France),Patrizio Lancellotti (Belgium),Luc Pierard (Belgium),Susanna Price (UK),Hans-Joachim Scha ¨fers (Germany),Gerhard Schuler (Germany),Janina Stepinska (Poland),Karl Swedberg (Sweden),Johanna Takkenberg (The Netherlands),Ulrich Otto Von Oppell (UK),Stephan Windecker (Switzerland),Jose Luis Zamorano(Spain),Marian Zembala (Poland)ESC Committee for Practice Guidelines (CPG):Jeroen J.Bax (Chairperson)(The Netherlands),Helmut Baumgartner (Germany),Claudio Ceconi (Italy),Veronica Dean (France),Christi Deaton (UK),Robert Fagard (Belgium),Christian Funck-Brentano (France),David Hasdai (Israel),Arno Hoes (The Netherlands),Paulus Kirchhof(United Kingdom),Juhani Knuuti (Finland),Philippe Kolh (Belgium),Theresa McDonagh (UK),Cyril Moulin (France),Bogdan A.Popescu (Romania),Z ˇeljko Reiner (Croatia),Udo Sechtem (Germany),Per Anton Sirnes (Norway),Michal Tendera (Poland),Adam Torbicki (Poland),Alec Vahanian (France),Stephan Windecker (Switzerland)Document Reviewers::Bogdan A.Popescu (ESC CPG Review Coordinator)(Romania),Ludwig Von Segesser (EACTS Review Coordinator)(Switzerland),Luigi P.Badano (Italy),Matjaz ˇBunc (Slovenia),Marc J.Claeys (Belgium),Niksa Drinkovic (Croatia),Gerasimos Filippatos (Greece),Gilbert Habib (France),A.Pieter Kappetein (The Netherlands),Roland Kassab (Lebanon),Gregory Y.H.Lip (UK),Neil Moat (UK),Georg Nickenig (Germany),Catherine M.Otto (USA),John Pepper,(UK),Nicolo Piazza (Germany),Petronella G.Pieper (The Netherlands),Raphael Rosenhek (Austria),Naltin Shuka (Albania),Ehud Schwammenthal (Israel),Juerg Schwitter (Switzerland),Pilar Tornos Mas (Spain),Pedro T.Trindade (Switzerland),Thomas Walther (Germany)The disclosure forms of the authors and reviewers are available on the ESC website/guidelines Ottavio Alﬁeri,S.Raffaele University Hospital,20132Milan,Italy.Tel:+390226437109;Fax:+390226437125.Email:ottavio.alﬁeri@hsr.it †Other ESC entities having participated in the development of this document:Associations:European Association of Echocardiography (EAE),European Association of Percutaneous Cardiovascular Interventions (EAPCI),Heart Failure Association (HFA)Working Groups:Acute Cardiac Care,Cardiovascular Surgery,Valvular Heart Disease,Thrombosis,Grown-up Congenital Heart DiseaseCouncils:Cardiology Practice,Cardiovascular ImagingThe content of these European Society of Cardiology (ESC)Guidelines has been published for personal and educational use only.No commercial use is authorized.No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC.Permission can be obtained upon submission of a written request to Oxford University Press,the publisher of the European Heart Journal ,and the party authorized to handle such permissions on behalf of the ESC.*Corresponding authors:Alec Vahanian,Service de Cardiologie,Hopital Bichat AP-HP,46rue Henri Huchard,75018Paris,France.Tel:+33140256760;Fax:+33140256732.Email:alec.vahanian@bch.aphp.frDisclaimer .The ESC/EACTS Guidelines represent the views of the ESC and the EACTS and were arrived at after careful consideration of the available evidence at the time they were written.Health professionals are encouraged to take them fully into account when exercising their clinical judgement.The guidelines do not,however,override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients,in consultation with that patient and,where appropriate and necessary,the patient’s guardian or carer.It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.&The European Society of Cardiology 2012.All rights reserved.For permissions please email:journals.permissions@ European Heart Journal doi:10.1093/eurheartj/ehs109European Heart Journal Advance Access published August 24, 2012 by guest on August 26, 2012/Downloaded from医脉通w w w .m e d li v e.c n2.3.How to use these guidelines ..................53.General comments ............................53.1.Patient evaluation .........................53.1.1.Clinical evaluation ......................53.1.2.Echocardiography ......................63.1.3.Other non-invasive investigations ............63.1.3.1.Stress testing . (6)3.1.3.2.Cardiac magnetic resonance ...........puted tomography ...............73.1.3.4.Fluoroscopy .......................83.1.3.5.Radionuclide angiography ..............83.1.3.6.Biomarkers .......................83.1.4.Invasive investigations ....................83.1.5.Assessment of comorbidity ................83.2.Endocarditis prophylaxis .....................83.3.Prophylaxis for rheumatic fever ................83.4.Risk stratiﬁcation ..........................83.5.Management of associated conditions ............93.5.1.Coronary artery disease ..................93.5.2.Arrhythmias ..........................94.Aortic regurgitation ............................104.1.Evaluation ..............................104.2.Natural history ...........................104.3.Results of surgery .........................104.4.Indications for surgery ......................114.5.Medical therapy...........................124.6.Serial testing .............................134.7.Special patient populations ...................135.Aortic stenosis ...............................135.1.Evaluation ..............................135.2.Natural history ...........................145.3.Results of intervention ......................145.4.Indications for intervention ...................155.4.1.Indications for aortic valve replacement ........155.4.2.Indications for balloon valvuloplasty ..........165.4.3.Indications for transcatheter aortic valve implantation ..............................175.5.Medical therapy...........................185.6.Serial testing .............................185.7.Special patient populations ...................196.Mitral regurgitation ............................196.1.Primary mitral regurgitation ...................196.1.1.Evaluation............................206.1.2.Natural history ........................20 6.2.1.Evaluation. (23)6.2.2.Natural history (23)6.2.3.Results of surgery (24)6.2.4.Percutaneous intervention (24)6.2.5.Indications for intervention (24)6.2.6.Medical treatment (25)7.Mitral stenosis ...............................257.1.Evaluation ..............................257.2.Natural history ...........................257.3.Results of intervention . (25)7.3.1.Percutaneous mitral commissurotomy (25)7.3.2.Surgery (26)7.4.Indications for intervention (26)7.5.Medical therapy...........................277.6.Serial testing .. (28)7.7.Special patient populations (28)8.Tricuspid regurgitation (28)8.1.Evaluation (28)8.2.Natural history (29)8.3.Results of surgery .........................298.4.Indications for surgery . (29)8.5.Medical therapy (30)9.Tricuspid stenosis (30)9.1.Evaluation (30)9.2.Surgery (30)9.3.Percutaneous intervention (30)9.4.Indications for intervention (30)9.5.Medical therapy (30)bined and multiple valve diseases (30)11.Prosthetic valves (30)11.1.Choice of prosthetic valve (30)11.2.Management after valve replacement (32)11.2.1.Baseline assessment and modalities of follow-up .3211.2.2.Antithrombotic management (32)11.2.2.1.General management (32)11.2.2.2.Target INR (33)11.2.2.3.Management of overdose of vitamin Kantagonists and bleeding (34)bination of oral anticoagulants withantiplatelet drugs (34)11.2.2.5.Interruption of anticoagulant therapy (34)11.2.3.Management of valve thrombosis (35)11.2.4.Management of thromboembolism (35)11.2.5.Management of haemolysis and paravalvular leak .35ESC/EACTS Guidelines Page 2of 46 by guest on August 26, 2012/Downloaded from医脉通w w w .m e d l i v e .c n 11.2.6.Management of bioprosthetic failure .........3511.2.7.Heart failure .........................3712.Management during non-cardiac surgery ..............................3712.1.Preoperative evaluation .....................3812.2.Speciﬁc valve lesions.......................3812.2.1.Aortic stenosis .......................3812.2.2.Mitral stenosis ........................3812.2.3.Aortic and mitral regurgitation .............3912.2.4.Prosthetic valves ......................3912.3.Perioperative monitoring ....................3913.Management during pregnancy .. (39)13.1.Native valve disease (39)13.2.Prosthetic valves (39)References ....................................39Abbreviations and acronyms ACE angiotensin-converting enzyme AF atrial ﬁbrillation aPTT activated partial thromboplastin time AR aortic regurgitation ARB angiotensin receptor blockers AS aortic stenosis AVR aortic valve replacement BNP B-type natriuretic peptide BSA body surface area CABG coronary artery bypass grafting CAD coronary artery disease CMR cardiac magnetic resonance CPG Committee for Practice Guidelines CRT cardiac resynchronization therapy CT computed tomography EACTS European Association for Cardio-Thoracic Surgery ECG electrocardiogram EF ejection fraction EROA effective regurgitant oriﬁce area ESC European Society of Cardiology EVEREST (Endovascular Valve Edge-to-Edge REpair STudy)HF heart failure INR international normalized ratio LA left atrial LMWH low molecular weight heparin LV left ventricular LVEF left ventricular ejection fraction LVEDD left ventricular end-diastolic diameter LVESD left ventricular end-systolic diameter MR mitral regurgitation MS mitral stenosis MSCT multi-slice computed tomography NYHA New York Heart Association PISA proximal isovelocity surface area PMC percutaneous mitral commissurotomy PVL paravalvular leak RV right ventricular rtPA recombinant tissue plasminogen activator SVD structural valve deteriorationSTS Society of Thoracic SurgeonsTAPSE tricuspid annular plane systolic excursionTAVI transcatheter aortic valve implantationTOE transoesophageal echocardiographyTR tricuspid regurgitationTS tricuspid stenosisTTE transthoracic echocardiographyUFH unfractionated heparinVHD valvular heart disease3DE three-dimensional echocardiography1.PreambleGuidelines summarize and evaluate all evidence available,at thetime of the writing process,on a particular issue with the aim ofassisting physicians in selecting the best management strategiesfor an individual patient with a given condition,taking intoaccount the impact on outcome,as well as the risk-beneﬁt-ratio of particular diagnostic or therapeutic means.Guidelines are not substitutes for-,but complements to,textbooks and cover the ESC Core Curriculum topics.Guidelines and recommendations should help physicians to make decisions in their daily practice.However,the ﬁnal decisions concerning an individual patient must be made by the responsible physician(s).A great number of guidelines have been issued in recent years by the European Society of Cardiology (ESC)as well as by other societies and organisations.Because of their impact on clinical practice,quality criteria for the development of guidelines have been established,in order to make all decisions transparent to the user.The recommendations for formulating and issuing ESC Guidelines can be found on the ESC web site (/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx ).ESC Guidelines represent the ofﬁcial position of the ESC on a given topic and are regularly updated.Members of this Task Force were selected by the ESC and Euro-pean Association for Cardio-Thoracic Surgery (EACTS)to repre-sent professionals involved with the medical care of patients with this pathology.Selected experts in the ﬁeld undertook a compre-hensive review of the published evidence for diagnosis,manage-ment and/or prevention of a given condition,according to ESC Committee for Practice Guidelines (CPG)and EACTS policy.A critical evaluation of diagnostic and therapeutic procedures was performed,including assessment of the risk–beneﬁt ratio.Esti-mates of expected health outcomes for larger populations were included,where data exist.The levels of evidence and the strengths of recommendation of particular treatment options were weighed and graded according to predeﬁned scales,as outlined in Tables 1and 2.The experts of the writing and reviewing panels ﬁlled in Declara-tions of Interest forms dealing with activities which might be per-ceived as real or potential sources of conﬂicts of interest.These forms were compiled into one ﬁle and can be found on the ESC web site (/guidelines ).Any changes in declarations of interest that arise during the writing period must be notiﬁed to the ESC and EACTS and updated.The Task Force ESC/EACTS Guidelines Page 3of 46by guest on August 26, 2012/Downloaded fromw w w .m e d l i v e received its entire ﬁnancial support from the ESC and EACTS,without any involvement from the healthcare industry.The ESC CPG,in collaboration with the Clinical Guidelines Committee of EACTS,supervises and co-ordinates the preparation of these new Guidelines.The Committees are also responsible for the endorsement process of these Guidelines.The ESC/EACTS Guidelines undergo extensive review by the CPG,the Clinical Guidelines Committee of EACTS and external experts.After ap-propriate revisions,it is approved by all the experts involved in the Task Force.The ﬁnalized document is approved by the CPG for publication in the European Heart Journal and the European Journal of Cardio-Thoracic Surgery .After publication,dissemination of the message is of paramountimportance.Pocket-sized versions and personal digital assistant (PDA)downloadable versions are useful at the point of care.Some surveys have shown that the intended end-users are some-times unaware of the existence of guidelines,or simply do not translate them into practice,so this is why implementation pro-grammes for new guidelines form an important component of the dissemination of knowledge.Meetings are organized by theESC and EACTS and directed towards their member National So-cieties and key opinion-leaders in Europe.Implementation meet-ings can also be undertaken at national levels,once theguidelines have been endorsed by the ESC and EACTS membersocieties and translated into the national language.Implementation programmes are needed because it has been shown that theoutcome of disease may be favourably inﬂuenced by the thoroughapplication of clinical recommendations.Thus the task of writing these Guidelines covers not only theintegration of the most recent research,but also the creation ofeducational tools and implementation programmes for the recom-mendations.The loop between clinical research,writing of guide-lines and implementing them into clinical practice can only thenbe completed if surveys and registries are performed to verify that real-life daily practice is in keeping with what is recommended in the guidelines.Such surveys and registries also make it possible to evaluate the impact of implementation of the guidelines on patient outcomes.The guidelines do not,however,override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient,in consultation with that patient and—where appropriate and necessary—the patient’s guardian or carer.It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.2.Introduction2.1Why do we need new guidelines on valvular heart disease?Although valvular heart disease (VHD)is less common in industria-lized countries than coronary artery disease (CAD),heart failure by guest on August 26, 2012/Downloaded from医脉通w w w .m e d l .c n (HF),or hypertension,guidelines are of interest in this ﬁeld because VHD is frequent and often requires intervention.1,2Decision-making for intervention is complex,since VHD is oftenseen at an older age and,as a consequence,there is a higher fre-quency of comorbidity,contributing to increased risk of interven-tion.1,2Another important aspect of contemporary VHD is the growing proportion of previously-operated patients who present with further problems.1Conversely,rheumatic valve disease still remains a major public health problem in developing countries,where it predominantly affects young adults.3When compared with other heart diseases,there are few trials in the ﬁeld of VHD and randomized clinical trials are particularly scarce.Finally,data from the Euro Heart Survey on VHD,4,5conﬁrmed by other clinical trials,show that there is a real gap between the existing guidelines and their effective application.6–9We felt that an update of the existing ESC guidelines,8published in 2007,was necessary for two main reasons:†Firstly,new evidence was accumulated,particularly on risk stratiﬁcation;in addition,diagnostic methods—in particularechocardiography—and therapeutic options have changed dueto further development of surgical valve repair and the introduc-tion of percutaneous interventional techniques,mainly trans-catheter aortic valve implantation (TAVI)and percutaneousedge-to-edge valve repair.These changes are mainly relatedto patients with aortic stenosis (AS)and mitral regurgitation (MR).†Secondly,the importance of a collaborative approach between cardiologists and cardiac surgeons in the management ofpatients with VHD—in particular when they are at increased perioperative risk—has led to the production of a joint docu-ment by the ESC and EACTS.It is expected that this joint effort will provide a more global view and thereafter facilitate implementation of these guidelines in both communities.2.2Contents of these guidelinesThese guidelines focus on acquired VHD,are oriented towardsmanagement,and do not deal with endocarditis or congenital valve disease,including pulmonary valve disease,since recent guidelines have been produced by the ESC on these topics.10,11Finally,these guidelines are not intended to include detailed infor-mation covered in ESC Guidelines on other topics,the ESC Asso-ciation/Working Group’s recommendations,position statementsand expert consensus papers and the speciﬁc sections of the ESC Textbook of Cardiovascular Medicine .122.3How to use these guidelines The Committee emphasizes that many factors ultimately deter-mine the most appropriate treatment in individual patients within a given community.These factors include availability of diagnostic equipment,the expertise of cardiologists and surgeons—especially in the ﬁeld of valve repair and percutaneous intervention—and,notably,the wishes of well-informed patients.Furthermore,due to the lack of evidence-based data in the ﬁeld of VHD,most recommendations are largely the result of expert consensus opinion.Therefore,deviations from these guidelines may be appro-priate in certain clinical circumstances.3.General commentsThe aims of the evaluation of patients with VHD are to diagnose,quantify and assess the mechanism of VHD,as well as its conse-quences.The consistency between the results of diagnostic inves-tigations and clinical ﬁndings should be checked at each step in the decision-making process.Decision-making should ideally be made by a ‘heart team’with a particular expertise in VHD,including car-diologists,cardiac surgeons,imaging specialists,anaesthetists and,if needed,general practitioners,geriatricians,or intensive care spe-cialists.This ‘heart team’approach is particularly advisable in the management of high-risk patients and is also important for other subsets,such as asymptomatic patients,where the evaluation of valve repairability is a key component in decision-making.Decision-making can be summarized according to the approach described in Table 3.Finally,indications for intervention—and which type of interven-tion should be chosen—rely mainly on the comparative assess-ment of spontaneous prognosis and the results of intervention according to the characteristics of VHD and comorbidities.3.1Patient evaluation3.1.1Clinical evaluationThe aim of obtaining a case history is to assess symptoms and toevaluate for associated comorbidity.The patient is questioned onhis/her lifestyle to detect progressive changes in daily activity inorder to limit the subjectivity of symptom analysis,particularly inthe elderly.In chronic conditions,adaptation to symptoms occurs:this also needs to be taken into consideration.Symptom development is often a driving indication for intervention.Patients who currently deny symptoms,but have been treated for HF,should be classiﬁed as symptomatic.The reason for—and degree of—functional limitation should be documented in the records.In the presence of comorbidities it is important to consider the cause of the symptoms.ESC/EACTS Guidelines Page 5of 46 by guest on August 26, 2012/Downloaded from医脉通w w w .m e d l i v e.c3.1.2Echocardiography Echocardiography is the key technique used to conﬁrm the diagno-sis of VHD,as well as to assess its severity and prognosis.It should be performed and interpreted by properly trained personnel.14It is indicated in any patient with a murmur,unless no suspicion of valve disease is raised after the clinical evaluation.The evaluation of the severity of stenotic VHD should combine the assessment of valve area with ﬂow-dependent indices such as mean pressure gradient and maximal ﬂow velocity (Table 4).15Flow-dependent indices add further information and have a prognostic value.The assessment of valvular regurgitation should combine different indices including quantitative measurements,such as the vena contracta and effective regurgitant oriﬁce area (EROA),which is less dependent on ﬂow conditions than colour Doppler jet size (Table 5).16,17However,all quantitative evaluations have limitations.In particular,they combine a number of measurements and are highly sensitive to errors of measurement,and are highly operator-dependent;there-fore,their use requires experience and integration of a number of measurements,rather than reliance on a single parameter.Thus,when assessing the severity of VHD,it is necessary to check consistency between the different echocardiographic measure-ments,as well as the anatomy and mechanisms of VHD.It is alsonecessary to check their consistency with the clinical assessment.Echocardiography should include a comprehensive evaluation of all valves,looking for associated valve diseases,and the aorta.Indices of left ventricular (LV)enlargement and function are strong prognostic factors.While diameters allow a less complete assessment of LV size than volumes,their prognostic value has been studied more extensively.LV dimensions should be indexed to body surface area (BSA).The use of indexed values is of particu-lar interest in patients with a small body size but should be avoided in patients with severe obesity (body mass index .40kg/m 2).Indices derived from Doppler tissue imaging and strain assessments seem to be of potential interest for the detection of early impair-ment of LV function but lack validation of their prognostic value for clinical endpoints.Finally,the pulmonary pressures should be evaluated,as well asright ventricular (RV)function.18Three-dimensional echocardiography (3DE)is useful for asses-sing anatomical features which may have an impact on the type of intervention chosen,particularly on the mitral valve.19Transoesophageal echocardiography (TOE)should be consid-ered when transthoracic echocardiography (TTE)is of suboptimal quality or when thrombosis,prosthetic dysfunction,or endocardi-tis is suspected.Intraprocedural TOE enables us to monitor the results of surgical valve repair or percutaneous procedures.High-quality intraoperative TOE is mandatory when performing valve repair.Three-dimensional TOE offers a more detailed exam-ination of valve anatomy than two-dimensional echocardiography and is useful for the assessment of complex valve problems or for monitoring surgery and percutaneous intervention.3.1.3Other non-invasive investigations3.1.3.1Stress testingStress testing is considered here for the evaluation of VHD and/or its consequences,but not for the diagnosis of associated CAD.Predictive values of functional tests used for the diagnosis of CAD may not apply in the presence of VHD and are generally not used in this setting.20Exercise ECGThe primary purpose of exercise testing is to unmask the objective occurrence of symptoms in patients who claim to be asymptomatic or have doubtful symptoms.Exercise testing has an additional value for risk stratiﬁcation in AS.21Exercise testing will also determine the level of authorised physical activity,including participation in sports.Exercise echocardiographyExercise echocardiography may provide additional information in order to better identify the cardiac origin of dyspnoea—which is a rather unspeciﬁc symptom—by showing,for example,an increase in the degree of mitral regurgitation/aortic gradient and in systolic pulmonary pressures.It has a diagnostic value in transi-ent ischaemic MR,which may be overlooked in investigations at by guest on August 26, 2012/Downloaded fromw w w.m rest.The prognostic impact of exercise echocardiography has been mainly shown for AS and MR.However,this technique is not widely accessible,could be technically demanding,and requires speciﬁc expertise.Other stress tests The search for ﬂow reserve (also called contractile reserve)using low-dose dobutamine stress echocardiography is useful for asses-sing severity and operative risk stratiﬁcation in AS with impaired LV function and low gradient.223.1.3.2Cardiac magnetic resonance In patients with inadequate echocardiographic quality or discrepant results,cardiac magnetic resonance (CMR)should be used to assess the severity of valvular lesions—particularly regurgitant lesions—and to assess ventricular volumes and systolic function,as CMR assesses these parameters with higher reproducibility than echocardiography.23CMR is the reference method for the evaluation of RV volumes and function and is therefore useful to evaluate the consequences of tricuspid regurgitation (TR).In practice,the routine use of CMR is limited because of its limited availability,compared with echocardiography.3.1.3.3Computed tomographyMulti-slice computed tomography (MSCT)may contribute tothe evaluation of the severity of valve disease,particularly in AS,either indirectly by quantifying valvular calciﬁcation,or dir-ectly through the measurement of valve planimetry.24,25It iswidely used to assess the severity and location of an aneurysmof the ascending aorta.Due to its high negative predictive value,MSCT may be useful in excluding CAD in patients who are at low risk of atherosclerosis.25MSCT plays an important role in the work-up of high-risk patients with AS considered for TAVI.26,27The risk of radiation exposure—and of renal failure due to contrast injection—should,however,be taken into consideration.Both CMR and MSCT require the involvement of radiologists/cardiologists with special expertise in VHD imaging.28 by guest on August 26, 2012/Downloaded from。

ESC心脏瓣膜病指南解读

2.1.Coronary artery disease
Part 2.Management of associated conditions
2.2.Atrial fibrillation
Part 2.Management of associated conditions
2.2.Atrial fibrillation
Part 4.Aortic stenosis
4.1.Introduction
GOAL
Part 4.Aortic stenosis
4.2.Management of severe AS
Part 4.Aortic stenosis
4.3.Indications for intervention
Part 4.Aortic stenosis
Part 1. Introduction & Patient evaluation
1.2.Patient evaluation
Other non-invasive investigations Invasive investigations
Stress testing Cardiac magnetic resonance Computed tomography Cinefluoroscopy Biomarkers（BNP）
CONTENTS
1.Introduction & Patient evaluation
2.Management of associated conditions 3.Aortic regurgitation 4.Aortic stenosis 5.Mitral regurgitation 6.Mitral stenosis

2014年心脏瓣膜病患者管理指南

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2020心脏瓣膜病患者管理指南

2020心脏瓣膜病患者管理指南英文回答：Heart valve disease refers to any condition thataffects the valves of the heart, preventing them from properly opening and closing. This can lead to a variety of symptoms and complications, including shortness of breath, chest pain, fatigue, and even heart failure. Managing heart valve disease is crucial to improve the patient's quality of life and prevent further complications.One important aspect of managing heart valve disease is regular monitoring and evaluation. This involves regular check-ups with the healthcare provider to assess the condition of the heart valves and monitor any changes or progression of the disease. Diagnostic tests such as echocardiograms, electrocardiograms, and stress tests may be performed to evaluate the function of the heart and determine the severity of the valve disease.In addition to monitoring, lifestyle modifications are often recommended to manage heart valve disease. These may include maintaining a healthy diet, engaging in regular physical activity, quitting smoking, and managing stress. These lifestyle changes can help reduce the risk of further damage to the heart valves and improve overall cardiovascular health.Medication therapy is another important component of managing heart valve disease. Depending on the specific condition and severity, medications may be prescribed to control symptoms, prevent complications, and slow down the progression of the disease. For example, diuretics may be prescribed to reduce fluid buildup, beta-blockers tocontrol heart rate and blood pressure, and anticoagulants to prevent blood clots.In some cases, surgical intervention may be necessary to repair or replace the damaged heart valves. This can be done through open-heart surgery or minimally invasive procedures such as transcatheter valve replacement. The decision for surgery is based on the severity of the valvedisease, the presence of symptoms, and the overall healthof the patient.Regular follow-up care is essential for patients with heart valve disease. This includes ongoing monitoring ofthe condition, medication adjustments if needed, and addressing any concerns or symptoms that arise. It is important for patients to communicate with their healthcare provider and adhere to the recommended treatment plan to effectively manage the disease.中文回答：心脏瓣膜病是指影响心脏瓣膜正常开闭的任何疾病。

ESC瓣膜性心脏病管理指南

ESC瓣膜性心脏病管理指南（2012年版全文）——欧洲心脏学会（ESC）和欧洲心胸外科协会（EACTS）瓣膜性心脏病管理联合工作组目录表缩略语1．前言2．介绍2．1．我们为什么需要新的瓣膜性心脏病指南？2．2．这些指南的内容2．3．如何使用这些指南3．总体情况述评3．1．患者评估3．1．1．临床评估3．1．2．超声心动图3．1．3．其它非侵入性检查3．1．3．1．负荷试验3．1．3．2．心脏磁共振（CMR）3．1．3．3．计算机断层摄影3．1．3．4．荧光镜检查3．1．3．5．放射核素血管造影3．1．3．6．生物标志物3．1．4．侵入性检查3．1．5．合并症的评估3．2．心内膜炎的预防3．3．风湿热的预防3．4．危险分层3．5．相关情况的管理3．5．1．冠心病3．5．2．心律失常4．主动脉反流4．1．评估4．2．自然史4．3．手术结果4．4．手术适应症4．5．药物治疗4．6．连续检测4．7．特殊患者人群5．主动脉狭窄5．1．评估5．2．自然史5．3．介入治疗结果5．4．介入治疗的适应症5．4．1．主动脉瓣膜置换的适应症5．4．2．球囊瓣膜成形术的适应症5．4．3．经导管主动脉瓣置入的适应症5．5．药物治疗5．6．系列检测5．7．特殊患者人群6．二尖瓣反流6．1．原发性二尖瓣反流6．1．1．评估6．1．2．自然史6．1．3．手术结果6．1．4．经皮介入治疗6．1．5．介入治疗的适应症6．1．6．药物治疗6．1．7．系列检测6．2．继发性二尖瓣反流6．2．1．评估6．2．2．自然史6．2．3．手术结果6．2．4．经皮介入治疗6．2．5．介入治疗的适应症6．2．6．药物治疗7．二尖瓣狭窄7．1．评估7．2．自然史7．3．介入治疗的结果7．3．1．经皮二尖瓣连合部切开术7．3．2．手术7．4．介入治疗的适应症7．5．药物治疗7．6．系列检测7．7．特殊患者人群8．三尖瓣反流8．1．评估8．2．自然史8．3．手术结果8．4．手术适应症8．5．药物治疗9．三尖瓣狭窄9．1．评估9．2．手术9．3．经皮介入治疗9．4．介入治疗的适应症9．5．药物治疗10．联合瓣膜和多瓣膜病变11．人工瓣膜11．1．人工瓣膜的选择11．2．瓣膜置换后的管理11.2.1.基线评估和随访模式11. 2.2.抗栓治疗11.2.2..1.一般治疗11.2.2.2.目标INR11.2.2.3.维生素K拮抗剂过量和出血的处理11.2.2.4.口服抗凝剂与抗血小板药的联用11.2.2.5. 抗凝治疗的中断11.2.3.瓣膜血栓形成的处理11.2.4.血栓栓塞的处理11.2.5.溶血和瓣周漏的处理11.2.6.生物人工瓣膜失效的处理11.2.7.心力衰竭12.非心脏手术期间的管理12.1.围术期评估12.2.特殊瓣膜病变12.2.1.主动脉狭窄12.2.2.二尖瓣狭窄12.2.3.主动脉瓣和二尖瓣反流12.2.4.人工瓣膜12.3.围术期监测13.妊娠期间的管理13.1.自然瓣膜病变13.2.人工瓣膜病变参考文献缩略语ACE 血管紧张素转换酶AF 心房颤动aPTT活化部分凝血活酶时间AR 主动脉瓣反流ARB 血管紧张素受体抑制剂AS 主动脉狭窄AVB 主动脉瓣置换BNP B-型利钠肽BSA 体面面积CABG 冠状动脉旁路移植CAD 冠心病CMR 心脏磁共振CPG 实践指南委员会CRT 心脏再同步化治疗CT 计算机断层摄影EACTS 欧洲心胸外科医师协会ECG 心电图EF 射血分数EROA 有效反流口面积ESC 欧洲心脏学会EVEREST（血管内瓣膜边缘对边缘修复研究）HF 心力衰竭INR国际标准化比率LA 左房LMWH 低分子量肝素LV 左室LVEF 左室射血分数LVEDD 左室舒张末内径LVSED 左室收缩末内径MR 二尖瓣反流MS 二尖瓣狭窄MSCT 多层计算机断层摄影NYHA 纽约心脏协会PISA 近段等速线表面积PMC 经皮二尖瓣连合部切开术PVL 瓣周漏RV 右室r-tPA 重组组织型纤溶酶原激活物SVD 结构性瓣膜退化STS 美国胸外科医师协会TAPSE 三尖瓣环平面收缩偏移TAVI 经导管主动脉瓣植入术TEE 经食管超声心动图TR 三尖瓣反流TS 三尖瓣狭窄TTE 经胸超声心动图UFH 普通肝素VHD 瓣膜性心脏病3DE 3维超声心动图1.前言在指南的编写过程中，对一个指定的问题，编委们总结和评价了所有可用的证据，旨在帮助医师对有特定情况的每个患者，考虑对预后的影响以及特殊诊断或治疗方法的风险-获益比，选择最佳的处理对策。

心脏瓣膜病患者管理指南2020(第十部分)

心脏瓣膜病患者管理指南（第十部分）13.妊娠和心脏瓣膜病心脏结构正常的女性通常可以很好地耐受与妊娠相关的生理血流动力学变化。

然而，血流动力学的变化对于伴有心脏瓣膜病的女性可能在妊娠和分娩中构成重大威胁。

13.1妊娠前和妊娠期间对伴有心脏瓣膜病女性的初步管理概要为了确保伴有心脏瓣膜病女性及其婴儿能得到的最佳结果，在妊娠前应进行综合评估。

妊娠期间，瓣膜病变的类型和严重程度以及患者的症状决定了随访和治疗的频率和重视程度。

具体推荐建议1.瓣膜疾病的类型和严重程度决定了妊娠期间孕妇和胎儿的风险程度。

临床上对妊娠期女性的评估需进行完整的经胸心脏彩超检查，包括对瓣膜进行完整的解剖和血流动力学评估（1-5）。

先天性主动脉瓣二叶畸形或单瓣畸形常与主动脉窦部、升主动脉或两者都扩张有关。

对先天性主动脉瓣异常女性的孕前应行主动脉的评估，因为妊娠期间有主动脉进一步增大和夹层的风险（1-5）。

2.孕前向具有管理心脏瓣膜病女性患者经验的心脏病专家进行咨询可了解妊娠对孕妇和胎儿的风险。

完整评估瓣膜功能、瓣膜病变的严重程度、左右心室状态和肺动脉压力是确定妊娠和分娩风险的必要条件。

评估药物使用情况以避免可能对胎儿有潜在的危害的因素。

孕前评估还包括孕前干预方法的选择，如瓣膜置换，瓣膜修复，或经皮主动脉瓣或二尖瓣球囊扩张，特别是对于严重风湿性MS或AS患者（1-5）。

3.妊娠合并有严重瓣膜疾病的女性具有发病率和死亡率升高的风险。

这些孕妇所生下的婴儿也有严重并发症的风险。

拥有擅长管理妊娠期间高风险心脏病患者的医疗团队的三级医院的护理，可使得并发症的识别和处理得到提升（1-12）。

4. 严重瓣膜疾病的患者可能无症状，这给在考虑妊娠的女性造成诊断和治疗的困境。

运动测试可以帮助评估在未进行瓣膜修复或置换手术的情况下是否能忍受妊娠（3 - 5，11，13 - 15）。

运动测试引起的症状等同于自发性症状。

在运动测试中出现症状的患者应被视为有症状性瓣膜疾病（D 期），并应向具有管理妊娠期心脏瓣膜病的专家进行孕前咨询。

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指南不是教科书的替代而是补充，并覆盖了ESC的核心课程主题。

指南和推荐应有助于医师在其日常实践中做决策；然而，对于某个具体患者的最终诊疗方案，必须由其主诊医师来决定。

最近几年，ESC及其它学会和机构已经发布了许多的指南。

由于其对临床实践的影响，ESC已经建立了指南开发的质量标准，以使所有决策让使用者明了。

制定和发布ESC指南的推荐可在ESC网站：( /guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx) 上找到。

ESC指南代表对指定主题的ESC官方立场，并定期更新。

这个工作组的成员是由ESC挑选的，能代表与医疗护理本病患者相关的专业人员。

所选的本领域的专家，按照ESC实践指南委员会（CPG）的方针，承担对已发表的指定情况的诊断、治疗和预防证据的全面复习。

要完成诊断和治疗程序的评估，包括风险-获益比的评估。

只要有数据，对较大人群的预期健康预后的评估都包括在内。

象表A和表B所列那样，权衡特殊治疗选择的证据水平和推荐强度，并根据预先设定的等级分级。

写作和综述小组的专家，要填写可能被视为现实或可能利益冲突来源的、所有关系的利益表格声明。

这些表格被编辑成一个文件，并能在ESC网站(/guidelines )上找到。

在写作期间出现利益声明的任何变化，必须通知ESC并进行更新。

工作组得到ESC其完全的财政支持，与医疗保健产业没有任何牵连。

ESC CPG监督和协调由工作组、专家组或共识小组撰写新指南的准备工作。

委员会还负责这些指南的认证。

ESC指南要由CPG和外部专家进行广泛的复审。

经适当地修正后，指南要经工作组的全部专家认可。

定稿的文件须经CPG批准才能在欧洲心脏杂志发表。

开发ESC指南的工作不仅包含了最近研究的汇总，而且也包含了教育工具和推荐实施方案的创造。

为了实施这个指南，制作了袖珍指南版本、简易的幻灯片、基本信息的小册子和数字应用的电子版本（智能手机等）。

这些版本是省略的，因此，如果需要的话人们应经常参考在ESC网站免费可用的全文版本。

鼓励ESC成员各国学会支持、翻译并执行ESC指南。

实施方案是必需的，因为已经表明，疾病的预后可能受到彻底应用临床推荐的有利影响。

调查和登记都是需要的，以确认现实生活中的日常实践并保持与指南推荐的要求一致，从而完成临床研究、指南写作及实施到临床实践之间的环路。

然而，这个指南并没有覆盖个人健康专业人士在患者个体的情况下，与患者并在适当和必须时与患者的监护人或看护者磋商，作出适当决定的责任。

在开处方时，验证适用于药物和装置的规章制度也是卫生专业人员的责任。

2. 介绍2.1.我们为什么需要瓣膜性心脏病的新指南?虽然在工业化国家瓣膜性心脏病(VHD比冠心病(CAD、心力衰竭（HF）或高血压少见，但指南对这个领域感兴趣，因为VHD常见，且常常需要介入治疗（1，2）。

介入治疗决策是复杂的，因为VHD常见于老年人，因此，其共病的机率较高，使介入治疗的风险增高2。

当代VHD另一个重要的方面，是既往手术治疗的患者比例正在增长，呈现出进一步的问题1。

而在发展中国家，主要影响年轻人的风湿性心瓣膜病，仍然是一个重大的公共卫生问题（3）。

与其他的心脏病相比，在VHD领域的试验研究较少，随机临床试验尤其缺乏。

最后，经其他临床试验证实，关于VHD来自欧洲心脏调查的资料（4，5）显示，在现行的指南和其有效应用之间存在着现实的差距（6-9）。

我们感到2007年发表的现行ESC指南需要一次更新，主要原因有二：·首先，已经积累了新的证据，特别是危险分层的证据，此外，诊断方法（特别是超声心动图），和由于手术瓣膜修复技术的进一步开发和经皮介入治疗技术，主要是经导管主动脉瓣植入术（TAVI）和经皮边缘对边缘瓣膜修复术的引入，治疗选择已有变化。

这些变化主要与主动脉瓣狭窄（AS）和二尖瓣反流（MR）患者相关。

·其次，心脏科医师和心脏外科医师协作处理VHD患者，尤其是当其围术期风险增高时，非常重要，这已使得ESC和欧洲心胸外科学会（EACTS）联合开发了一份文件。

预期这种联合的努力将提供一种更整体的观念，从而促进这些指南在两个团体内的实施。

2．2．这些指南的内容这些指南重点针对获得性VHD，以治疗为导向，而不涉及心内膜炎或包括肺动脉瓣病变在内的先天性瓣膜病变，因为最近ESC已经对这些专题开发了指南（10，11）。

最后，这些指南不打算包括ESC指南其他专题、ESC协会/工作组的推荐、立场声明、专家共识文件和ESC心血管内科教科书（12）专题部分涵盖了的详细信息。

2．3．如何使用这些指南委员会强调很多因素最终决定一个特定社区内个体患者的最适宜治疗。

这些因素包括诊断设备的可及性、心血管内科和外科专家，特别是瓣膜修复和经皮介入领域的专家、以及见识多的患者的愿望。

而且，由于在VHD领域缺乏循证资料，大多数推荐主要是专家共识意见的结果。

因此，在某些临床情况下，来自这些指南的偏差可能是适当的。

3．总体情况述评评估VHD患者的目的是诊断、定量并评估VHD的机制及后果。

诊断研究结果和临床表现的一致性，在决策过程的每一步都应当核查。

最理想的，决策应当VHD专家组成的‘心脏团队’来做，这个团队包括心脏病学家、心脏外科医师、影像学专家、麻醉专家、必要时还包括全科医师、老年病学专家或重症监护专家。

这种‘心脏团队’的方法对高危患者的管理是特别可取的，且对其他亚组如无症状的患者也是很重要的，而瓣膜修复的评估是决策的关键部分。

决策可按表3所述的方法来总结。

最后，介入治疗的适应症及其应选择的介入类型，根据VHD和合并症的特征，主要依赖介入治疗的自发性预后和结果的比较性评估。

·应当根据年龄、性别、并发症发生率和国家特异的预期寿命估计平均寿命。

3．1．患者评估3．1．1．临床评估获得一份病史的目的是评估症状和相关的共病。

要询问患者的生活方式，便于检出其日常活动的进行性变化，以限制症状分析的主观性，特别是在老年人。

在慢性情况下，还需要考虑对症状可产生适应。

症状的发生常常是驱动干预的一个指征。

当前否认症状但曾治疗过HF的患者，应当分为有症状。

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