Aortic insufficiency cardiac catheterization: Difference between revisions

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__NOTOC__
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{{Aortic insufficiency}}
{{Aortic insufficiency}}
 
{{CMG}}; {{AE}} {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}, [[Varun Kumar]], M.B.B.S., [[Lakshmi Gopalakrishnan]], M.B.B.S.


==Overview==
==Overview==
Although echocardiography is now the primary imaging modality used to evaluate aortic insufficiency, cardiac catheterization is often performed in the patient with [[aortic insufficiency]] primarily to assess for the presence of epicardial coronary artery disease prior to surgical [[aortic valve replacement]]. Aortography can also be performed to assess the severity of aortic insufficiency. The presence or absence of an aortic dissection can be evaluated. Left ventricular function (hemodynamics), size and systolic function ([[ejection fraction]]) can also be evaluated.
Although [[echocardiography]] is now the primary imaging modality used to evaluate aortic insufficiency, [[cardiac catheterization]] is often performed in patients with aortic insufficiency primarily to assess for the presence of epicardial [[coronary artery]] disease prior to surgical [[aortic valve replacement]]. [[Aortography]] can also be performed to assess the severity of aortic insufficiency. The presence or absence of an [[aortic dissection]] can be evaluated. [[Left ventricular]] function (hemodynamics), size, and systolic function ([[ejection fraction]]) can also be evaluated.


==Performance of Aortography==
==Cardiac Catheterization==
The pigtail catheter is placed a few centimeters above the aortic root. The image intensifier is place in the 45 degree left anterior oblique view with no cranial or caudal angulation. Usually a total of 40 to 50 cc of dye is injected with approximately 20 cc administered every second. You should tell the patient that they can expect a warm feeling throughout their body.
[[Cardiac catheterization]] is the insertion of a [[catheter]] into a [[heart chamber|chamber]] or [[Blood vessel|vessel]] of the [[heart]]. This is done for both investigational and interventional purposes. [[Coronary catheterization]] is a subset of this technique, involving the catheterization of the [[coronary arteries]].
===Aortography Procedure===
A 4-6 F pigtail catheter is generally used to perform [[aortography]]. The pigtail catheter is placed a few centimeters above the [[aortic root]]. For aortic insufficiency quantification, the catheter is placed in the [[aortic root]] approximately 2 cm above the [[aortic valve]]. The image intensifier is placed in the 45 degree left anterior oblique view with no cranial or caudal angulation. Usually a total of 40 to 50 cc of dye is injected with approximately 20 cc administered every second. The patients should be informed that they can have a warm feeling throughout their body.
====Grading Aortic Insufficiency====
Grading the severity of aortic insufficiency is based on the amount of opacification of the [[left ventricle]], two complete [[cardiac cycle]]s after injection compared to that of the [[aortic root]].
*Grade 1
:Brief and incomplete ventricular opacification. Clears rapidly.
*Grade 2
:Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than [[aortic root]] opacification.
*Grade 3
:Opacification of the ventricle equal to [[aortic root]] opacification within 2 cycles. Delayed clearing of ventricle over several cycles.
*Grade 4
:Opacification of the ventricle almost immediately that is greater than that of the [[aortic root]] with delayed clearing of the ventricle.
{{#ev:youtube|in7AJXQZvEo}}


==Grading Aortic Insufficiency==
===Coronary Angiography===
The grade of aortic insufficiency is based on the opacification of the left ventricle 2 complete cardiac cycles after injection compared to that of the aortic root.
As a result of the regurgitant flow into the [[left ventricle]], there is greater than normal flow in the [[coronary arteries]] that tends to dilute the contrast. It can be quite difficult to fill the coronary arteries during a standard injection.


===Grade 1===   
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for management of CAD in valvular heart disease'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''[[Coronary angiography]] ([[ ESC  guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary angiography]] is recommended before [[valve]] surgery in [[patients]] with severe [[VHD]] and any of the following:
* History of [[cardiovascular disease]]<br>
* Suspected [[myocardial ischemia]]<br>
* [[Left ventricular]] [[systolic dysfunction]]<br>
* In men >40 years of age and [[postmenopausal]] [[women]]<br>
* One or more [[cardiovascular]] [[risk factors]]<br>
* Evaluation of severe [[mitral regurgitation]] <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' [[Coronary CT angiography]]  ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Coronary CT angiography]] is recommended as an alternative to [[coronary angiography]] before [[valve]] surgery in [[patients]] with severe [[VHD]] and low probability of [[CAD]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' [[CABG]]:([[ESC guidelines classification scheme|Class I, Level of Evidence C]]) :'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is considered in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid ]] valve surgery and [[coronary artery]] diameter stenosis ≥ 70%<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[CABG]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[CABG]] is recommended in [[patients]] undergone [[aortic]]/[[mitral]]/[[tricuspid]] valve surgery and [[coronary artery]] diameter [[stenosis]] ≥ 50-70% <br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''[[PCI]] : ([[AHA guidelines classification scheme|Class IIa, Level of Evidence C]])'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[PCI]] is recommended in [[patients]] undergoing [[TAVI]] and [[coronary artery]] diameter stenosis > 70% in proximal segments<br>
❑ [[PCI]] is recommended in [[patients]] undergoing [[transcatheter]] [[mitral valve]] intervention and [[coronary artery]] diameter stenosis > 70% in proximal segments<br>


Brief and incomplete ventricular opacification. Clears rapidly.
|}
----
<span style="font-size:85%">'''Abbreviations:'''
===Grade 2===
'''CAD:''' [[Coronary artery disease]];
'''CABG:''' [[Coronary artery bypass grafting]];
'''PCI:''' [[Percutaneous coronary intervention]];
'''TAVI:'''[[ Transcatheter aortic valve implantation]];
''' VHD:'''[[ Valvular heart disease]]
 
</span>
<br>


Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than aortic root opacification.
{|
 
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
{{#ev:googlevideo|2835396102193538399}}
|-
 
|}
----
===Grade 3===
 
Opacification of the ventricle equal to aortic root opacification within 2 cycles. Delayed clearing of ventricle over several cycles.


{{#ev:googlevideo|7844772248158567311}}
== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid33332150">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150  }}</ref> ==


----
===Grade 4=== 


Opacification of the ventricle almost immediately that is greater than that of the aortic root with delayed clearing of the ventricle.
Only when a diagnosis cannot be made with noninvasive imaging or when an acute coronary syndrome is a differential diagnosis should an angiography be explored.


{{#ev:googlevideo|1323435585463870537}}
==Coronary Angiography in the Patient with Aortic Insufficiency==
As a result of the regurgitant flow into the left ventricle, there is greater than normal flow in the coronary arteries that tends to dilute the contrast. It can be quite difficult to fill the coronary arteries during a standard injection.
==2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease - Indications for Cardiac Catheterization in Chronic Aortic Insufficiency (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==


==2008 Focused Update Incorporated into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
===Cardiac Catheterization Indications (DO NOT EDIT)<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is indicated for assessment of severity of [[regurgitation]], [[LV]] function, or [[aortic root]] size when noninvasive tests are inconclusive or discordant with clinical findings in patients with [[AR]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is indicated for assessment of severity of [[regurgitation]], [[LV]] function, or [[aortic root]] size when noninvasive tests are inconclusive or discordant with clinical findings in patients with [[AR]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Coronary angiography]] is indicated before [[AVR]] in patients at risk for [[CAD]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Coronary angiography]] is indicated before [[AVR]] in patients at risk for [[CAD]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
|}


Line 55: Line 98:
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is not indicated for assessment of [[LV]] function, [[aortic root]] size, or severity of [[regurgitation]] before [[AVR]] when noninvasive tests are adequate and concordant with clinical findings and [[coronary angiography]] is not needed. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is not indicated for assessment of [[LV]] function, [[aortic root]] size, or severity of [[regurgitation]] before [[AVR]] when noninvasive tests are adequate and concordant with clinical findings and [[coronary angiography]] is not needed. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is not indicated for assessment of [[LV]] function and severity of [[regurgitation]] in asymptomatic patients when noninvasive tests are adequate. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Cardiac catheterization]] with [[aortic root]] [[angiography]] and measurement of [[LV]] pressure is not indicated for assessment of [[LV]] function and severity of [[regurgitation]] in asymptomatic patients when noninvasive tests are adequate. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|}
|}


==Sources==
==Sources==
*2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>
*2008 focused update incorporated into the 2006 ACC/AHA guidelines for the management of patients with valvular heart disease<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[CME Category::Cardiology]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Valvular heart disease]]
[[Category:Congenital heart disease]]
[[Category:Surgery]]
[[Category:Cardiac surgery]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date]]

Latest revision as of 13:02, 8 December 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Although echocardiography is now the primary imaging modality used to evaluate aortic insufficiency, cardiac catheterization is often performed in patients with aortic insufficiency primarily to assess for the presence of epicardial coronary artery disease prior to surgical aortic valve replacement. Aortography can also be performed to assess the severity of aortic insufficiency. The presence or absence of an aortic dissection can be evaluated. Left ventricular function (hemodynamics), size, and systolic function (ejection fraction) can also be evaluated.

Cardiac Catheterization

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. Coronary catheterization is a subset of this technique, involving the catheterization of the coronary arteries.

Aortography Procedure

A 4-6 F pigtail catheter is generally used to perform aortography. The pigtail catheter is placed a few centimeters above the aortic root. For aortic insufficiency quantification, the catheter is placed in the aortic root approximately 2 cm above the aortic valve. The image intensifier is placed in the 45 degree left anterior oblique view with no cranial or caudal angulation. Usually a total of 40 to 50 cc of dye is injected with approximately 20 cc administered every second. The patients should be informed that they can have a warm feeling throughout their body.

Grading Aortic Insufficiency

Grading the severity of aortic insufficiency is based on the amount of opacification of the left ventricle, two complete cardiac cycles after injection compared to that of the aortic root.

  • Grade 1
Brief and incomplete ventricular opacification. Clears rapidly.
  • Grade 2
Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than aortic root opacification.
  • Grade 3
Opacification of the ventricle equal to aortic root opacification within 2 cycles. Delayed clearing of ventricle over several cycles.
  • Grade 4
Opacification of the ventricle almost immediately that is greater than that of the aortic root with delayed clearing of the ventricle.

{{#ev:youtube|in7AJXQZvEo}}

Coronary Angiography

As a result of the regurgitant flow into the left ventricle, there is greater than normal flow in the coronary arteries that tends to dilute the contrast. It can be quite difficult to fill the coronary arteries during a standard injection.

Recommendations for management of CAD in valvular heart disease
Coronary angiography (Class I, Level of Evidence C):

❑ Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following:

Coronary CT angiography (Class I, Level of Evidence C):

❑ Coronary CT angiography is recommended as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD

CABG:(Class I, Level of Evidence C) :

❑ CABG is considered in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 70%

CABG : (Class IIa, Level of Evidence C)

❑ CABG is recommended in patients undergone aortic/mitral/tricuspid valve surgery and coronary artery diameter stenosis ≥ 50-70%

PCI : (Class IIa, Level of Evidence C)

❑ PCI is recommended in patients undergoing TAVI and coronary artery diameter stenosis > 70% in proximal segments
❑ PCI is recommended in patients undergoing transcatheter mitral valve intervention and coronary artery diameter stenosis > 70% in proximal segments

Abbreviations: CAD: Coronary artery disease; CABG: Coronary artery bypass grafting; PCI: Percutaneous coronary intervention; TAVI:Transcatheter aortic valve implantation; VHD:Valvular heart disease


The above table adopted from 2021 ESC Guideline[1]

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[2]

Only when a diagnosis cannot be made with noninvasive imaging or when an acute coronary syndrome is a differential diagnosis should an angiography be explored.


2008 Focused Update Incorporated into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)[3]

Cardiac Catheterization Indications (DO NOT EDIT)[3]

Class I
"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is indicated for assessment of severity of regurgitation, LV function, or aortic root size when noninvasive tests are inconclusive or discordant with clinical findings in patients with AR. (Level of Evidence: B)"
"2. Coronary angiography is indicated before AVR in patients at risk for CAD. (Level of Evidence: C)"
Class III
"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function, aortic root size, or severity of regurgitation before AVR when noninvasive tests are adequate and concordant with clinical findings and coronary angiography is not needed. (Level of Evidence: C)"
"2. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function and severity of regurgitation in asymptomatic patients when noninvasive tests are adequate. (Level of Evidence: C)"

Sources

  • 2008 focused update incorporated into the 2006 ACC/AHA guidelines for the management of patients with valvular heart disease[3]

References

  1. ↑ Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
  2. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
  3. ↑ 3.0 3.1 3.2 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)

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