2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease

HomeCirculationVol. 129, No. 232014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUB2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart DiseaseA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Rick A. Nishimura, MD, MACC, FAHA, Catherine M. Otto, MD, FACC, FAHA, Robert O. Bonow, MD, MACC, FAHA, Blase A. Carabello, MD, FACC, John P. ErwinIII, MD, FACC, FAHA, Robert A. Guyton, MD, FACC, Patrick T. O’Gara, MD, FACC, FAHA, Carlos E. Ruiz, MD, PhD, FACC, Nikolaos J. Skubas, MD, FASE, Paul Sorajja, MD, FACC, FAHA, Thoralf M. SundtIII, MD and James D. Thomas, MD, FASE, FACC, FAHA Rick A. NishimuraRick A. Nishimura †ACC/AHA representative. Search for more papers by this author , Catherine M. OttoCatherine M. Otto †ACC/AHA representative. Search for more papers by this author , Robert O. BonowRobert O. Bonow †ACC/AHA representative. Search for more papers by this author , Blase A. CarabelloBlase A. Carabello *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , John P. ErwinIIIJohn P. ErwinIII ‡ACC/AHA Task Force on Performance Measures liaison. Search for more papers by this author , Robert A. GuytonRobert A. Guyton *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , Patrick T. O’GaraPatrick T. O’Gara †ACC/AHA representative. Search for more papers by this author , Carlos E. RuizCarlos E. Ruiz †ACC/AHA representative. Search for more papers by this author , Nikolaos J. SkubasNikolaos J. Skubas ¶Society of Cardiovascular Anesthesiologists representative. Search for more papers by this author , Paul SorajjaPaul Sorajja #Society for Cardiovascular Angiography and Interventions representative. Search for more papers by this author , Thoralf M. SundtIIIThoralf M. SundtIII *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author and James D. ThomasJames D. Thomas ‡‡American Society of Echocardiography representative. Search for more papers by this author Originally published3 Mar 2014https://doi.org/10.1161/CIR.0000000000000031Circulation. 2014;129:e521–e643is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 Table of ContentsPreamble e5231. Introduction e5231.1. Methodology and Evidence Review e5261.2. Organization of the Writing Committee e5261.3. Document Review and Approval e5261.4. Scope of the Guideline e5262. General Principles e5262.1. Evaluation of the Patient With Suspected VHD e5262.2. Definitions of Severity of Valve Disease e5272.3. Diagnosis and Follow-Up e5282.3.1. Diagnostic Testing–Initial Diagnosis: Recommendation e5282.3.2. Diagnostic Testing–Changing Signs or Symptoms: Recommendation e5282.3.3. Diagnostic Testing–Routine Follow-Up: Recommendation e5282.3.4. Diagnostic Testing–Cardiac Catheterization: Recommendation e5282.3.5. Diagnostic Testing–Exercise Testing: Recommendation e5292.4. Basic Principles of Medical Therapy e5292.4.1. Secondary Prevention of Rheumatic Fever: Recommendation e5302.4.2. IE Prophylaxis: Recommendations e5302.5. Evaluation of Surgical and Interventional Risk e5312.6. The Heart Valve Team and Heart Valve Centers of Excellence: Recommendations e5323. Aortic Stenosis e5343.1. Stages of Valvular AS e5343.2. Aortic Stenosis e5343.2.1. Diagnosis and Follow-Up e5343.2.1.1. Diagnostic Testing–Initial Diagnosis: Recommendations e5343.2.1.2. Diagnostic Testing–Changing Signs Or Symptoms e5363.2.1.3. Diagnostic Testing–Routine Follow-Up e5363.2.1.4. Diagnostic Testing–Cardiac Catheterization e5363.2.1.5. Diagnostic Testing–ExerciseTesting: Recommendations e5373.2.2. Medical Therapy: Recommendations e5373.2.3. Timing of Intervention: Recommendations e5383.2.4. Choice of Intervention: Recommendations e5424. Aortic Regurgitation e5454.1. Acute AR e5454.1.1. Diagnosis e5454.1.2. Intervention e5454.2. Stages of Chronic AR e5464.3. Chronic AR e5464.3.1. Diagnosis and Follow-Up e5464.3.1.1. Diagnostic Testing–Initial Diagnosis: Recommendations e5464.3.1.2. Diagnostic Testing–Changing Signs Or Symptoms e5474.3.1.3. Diagnostic Testing–Routine Follow-Up e5474.3.1.4. Diagnostic Testing–Cardiac Catheterization e5474.3.1.5. Diagnostic Testing–ExerciseTesting e5474.3.2. Medical Therapy: Recommendations e5484.3.3. Timing of Intervention: Recommendations e5485. Bicuspid Aortic Valve and Aortopathy e5505.1. Bicuspid Aortic Valve e5505.1.1. Diagnosis and Follow-Up e5505.1.1.1. Diagnostic Testing–Initial Diagnosis: Recommendations e5505.1.1.2. Diagnostic Testing–Routine Follow-Up: Recommendation e5515.1.2. Medical Therapy e5515.1.3. Intervention: Recommendations e5516. Mitral Stenosis e5526.1. Stages of MS e5526.2. Rheumatic MS e5526.2.1. Diagnosis and Follow-Up e5526.2.1.1. Diagnostic Testing–Initial Diagnosis: Recommendations e5526.2.1.2. Diagnostic Testing–Changing Signs Or Symptoms e5536.2.1.3. Diagnostic Testing–Routine Follow-Up e5546.2.1.4. Diagnostic Testing–Cardiac Catheterization e5546.2.1.5. Diagnostic Testing–ExerciseTesting: Recommendation e5556.2.2. Medical Therapy: Recommendations e5556.2.3. Intervention: Recommendations e5566.3. Nonrheumatic MS e5587. Mitral Regurgitation e5597.1. Acute MR e5597.1.1. Diagnosis and Follow-Up e5597.1.2. Medical Therapy e5597.1.3. Intervention e5597.2. Stages of Chronic MR e5607.3. Chronic Primary MR e5607.3.1. Diagnosis and Follow-Up e5607.3.1.1. Diagnostic Testing–Initial Diagnosis: Recommendations e5607.3.1.2. Diagnostic Testing–Changing Signs Or Symptoms e5627.3.1.3. Diagnostic Testing–Routine Follow-Up e5637.3.1.4. Diagnostic Testing–Cardiac Catheterization e5637.3.1.5. Diagnostic Testing–ExerciseTesting: Recommendations e5637.3.2. Medical Therapy: Recommendations e5647.3.3. Intervention: Recommendations e5647.4. Chronic Secondary MR e5677.4.1. Diagnosis and Follow-Up: Recommendations e5677.4.2. Medical Therapy: Recommendations e5687.4.3. Intervention: Recommendations e5688. Tricuspid Valve Disease e5708.1. Stages of TR e5708.2. Tricuspid Regurgitation e5708.2.1. Diagnosis and Follow-Up: Recommendations e5708.2.2. Medical Therapy: Recommendations e5728.2.3. Intervention: Recommendations e5738.3. Stages of Tricuspid Stenosis e5748.4. Tricuspid Stenosis e5748.4.1. Diagnosis and Follow-Up: Recommendations e5748.4.2. Medical Therapy e5758.4.3. Intervention: Recommendations e5759. Pulmonic Valve Disease e5759.1. Stages of Pulmonic Regurgitation e5759.2. Stages of Pulmonic Stenosis e57510. Mixed Valve Disease e57610.1. Mixed VHD e57610.1.1. Diagnosis and Follow-Up e57610.1.2. Medical Therapy e57610.1.3. Timing of Intervention e57610.1.4. Choice of Intervention e57711. Prosthetic Valves e57711.1. Evaluation and Selection of Prosthetic Valves e57711.1.1. Diagnosis and Follow-Up: Recommendations e57711.1.2. Intervention: Recommendations e57811.2. Antithrombotic Therapy for Prosthetic Valves e58011.2.1. Diagnosis and Follow-Up e58011.2.2. Medical Therapy: Recommendations e58111.3. Bridging Therapy for Prosthetic Valves e58311.3.1. Diagnosis and Follow-Up e58311.3.2. Medical Therapy: Recommendations e58311.4. Excessive Anticoagulation and Serious Bleeding With Prosthetic Valves: Recommendation e58411.5. Thromboembolic Events With Prosthetic Valves e58411.5.1. Diagnosis and Follow-Up e58411.5.2. Medical Therapy e58511.5.3. Intervention e58511.6. Prosthetic Valve Thrombosis e58611.6.1. Diagnosis and Follow-Up: Recommendations e58611.6.2. Medical Therapy: Recommendations e58711.6.3. Intervention: Recommendations e58711.7. Prosthetic Valve Stenosis e58811.7.1. Diagnosis and Follow-Up e58811.7.2. Medical Therapy e58811.7.3. Intervention: Recommendation e58811.8. Prosthetic Valve Regurgitation e58911.8.1. Diagnosis and Follow-Up e58911.8.2. Medical Therapy e58911.8.3. Intervention: Recommendations e58912. Infective Endocarditis e58912.1. IE: Overview e58912.2. Infective Endocarditis e59012.2.1. Diagnosis and Follow-Up: Recommendations e59012.2.2. Medical Therapy: Recommendations e59412.2.3. Intervention: Recommendations e59513. Pregnancy and VHD e59913.1. Native Valve Stenosis: Recommendations e59913.1.1. Diagnosis and Follow-Up: Recommendation e60013.1.2. Medical Therapy: Recommendations e60013.1.3. Intervention: Recommendations e60113.2. Native Valve Regurgitation e60313.2.1. Diagnosis and Follow-Up: Recommendations e60313.2.2. Medical Therapy: Recommendation e60413.2.3. Intervention: Recommendations e60413.3. Prosthetic Valves in Pregnancy e60513.3.1. Diagnosis and Follow-Up: Recommendations e60513.3.2. Medical Therapy: Recommendations e60614. Surgical Considerations e60914.1. Evaluation of Coronary Anatomy: Recommendations e60914.2. Concomitant Procedures e61014.2.1. Intervention for CAD: Recommendation e61014.2.2. Intervention for AF: Recommendations e61115. Noncardiac Surgery in Patients With VHD e61215.1. Diagnosis and Follow-Up e61215.2. Medical Therapy e61215.3. Intervention: Recommendations e61316. Evidence Gaps and Future Directions e61416.1. Prevention of Valve Disease—Stage A e61416.2. Medical Therapy to Treat or Prevent Disease Progression—Stage B e61416.3. Optimal Timing of Intervention—Stage C e61416.4. Better Options for Intervention—Stage D e614References e615Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e635Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) e637Appendix 3. Abbreviations e643PreambleThe medical profession should play a central role in evaluating evidence related to drugs, devices, and procedures for detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force on Practice Guidelines (Task Force) directs this effort by developing, updating, and revising practice guidelines for cardiovascular diseases and procedures.Experts in the subject under consideration are selected from both ACC and AHA to examine subject-specific data and write guidelines. Writing committees are specifically charged with performing a literature review; weighing the strength of evidence for or against particular tests, treatments, or procedures; and including estimates of expected health outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered, as well as frequency of follow-up and cost effectiveness. When available, information from studies on cost is considered; however, a review of data on efficacy and outcomes constitutes the primary basis for preparing recommendations in this guideline.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits, as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C, according to specific definitions. The schema for the COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. Studies are identified as observational, retrospective, prospective, or randomized, as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues with sparse available data, a survey of current practice among the clinician members of the writing committee is the basis for LOE C recommendations and no references are cited.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceA new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another are included for COR I and IIa, LOE A or B only.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACC/AHA guideline (primarily Class I)-recommended therapies. This new term, GDMT, is used herein and throughout subsequent guidelines.Because the ACC/AHA practice guidelines address patient populations (and clinicians) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.The ACC/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas are identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of relationships with industry and other entities (RWI) among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort.In December 2009, the ACC and AHA implemented a new RWI policy that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 includes the ACC/AHA definition of relevance). The Task Force and all writing committee members review their respective RWI disclosures during each conference call and/or meeting of the writing committee, and members provide updates to their RWI as changes occur. All guideline recommendations require a confidential vote by the writing committee and require approval by a consensus of the voting members. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2. Members may not draft or vote on any recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members with specific section recusals noted in Appendix 1. In addition, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement.Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The ACC and AHA exclusively sponsor the work of the writing committee without commercial support. Writing committee members volunteered their time for this activity. Guidelines are official policy of both the ACC and AHA.In an effort to maintain relevance at the point of care for clinicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust.2,3 It is noteworthy that the Institute of Medicine cited ACC/AHA practice guidelines as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update, the full-text guideline is revised, or until a published addendum declares it out of date and no longer official ACC/AHA policy.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive review was conducted on literature published through November 2012, and other selected references through October 2013 were reviewed by the guideline writing committee. Searches were extended to studies, reviews, and other evidence conducted on human subjects and that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: valvular heart disease, aortic stenosis, aortic regurgitation, bicuspid aortic valve, mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonic stenosis, pulmonic regurgitation, prosthetic valves, anticoagulation therapy, infective endocarditis, cardiac surgery, and transcatheter aortic valve replacement. Additionally, the committee reviewed documents related to the subject matter previously published by the ACC and AHA. The references selected and published in this document are representative and not all-inclusive.1.2. Organization of the Writing CommitteeThe committee was composed of clinicians, who included cardiologists, interventionalists, surgeons, and anesthesiologists. The committee also included representatives from the American Association for Thoracic Surgery, American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons (STS).1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by both the ACC and the AHA, as well as 1 reviewer each from the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and STS and 39 individual content reviewers (which included representatives from the following ACC committees and councils: Adult Congenital and Pediatric Cardiology Section, Association of International Governors, Council on Clinical Practice, Cardiovascular Section Leadership Council, Geriatric Cardiology Section Leadership Council, Heart Failure and Transplant Council, Interventional Council, Lifelong Learning Oversight Committee, Prevention of Cardiovascular Disease Committee, and Surgeon Council). Reviewers’ RWI information was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and AHA and endorsed by the American Association for Thoracic Surgery, ASE, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and STS.1.4. Scope of the GuidelineThe focus of this guideline is the diagnosis and management of adult patients with valvular heart disease (VHD). A full revision of the original 1998 VHD guideline was made in 2006, and an update was made in 2008.4 Some recommendations from the earlier VHD guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were inaccurate, irrelevant, or overlapping were deleted or modified. Throughout, our goal was to provide the clinician with concise, evidence-based, contemporary recommendations and the supporting documentation to encourage their use.This guideline was created in a different format from prior VHD guidelines to facilitate access to concise, relevant bytes of information at the point of care when clinical knowledge is needed the most. Thus, each COR is followed by a brief paragraph of supporting text and references. Where applicable, sections were divided into subsections of 1) diagnosis and follow-up, 2) medical therapy, and 3) intervention. The purpose of these subsections was to categorize the COR according to the clinical decision-making pathways that caregivers use in the management of patients with VHD. New recommendations for assessment of the severity of valve lesions have been proposed, based on current natural history studies of patients with VHD.The present document applies to adult patients with VHD. Management of patients with congenital heart disease and infants and children with valve disease are not addressed here. The document recommends a combination of lifestyle modifications and medications that constitute GDMT. Both for GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to carefully evaluate for contraindications and drug–drug interactions. Table 2 is a list of associated guidelines that may be of interest to the reader. The table is intended for use as a resource and obviates the need to repeat extant guideline recommendations.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year/ReferenceRecommendations for Evaluation of the Severity of Native Valvular Regurgitation With Two-Dimensional and Doppler EchocardiographyASE20035Guidelines for the Management of Adults With Congenital Heart DiseaseACC/AHA20087Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical PracticeEAE/ASE20098Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler UltrasoundASE20099Guideline for the Diagnosis and Treatment of Hypertrophic CardiomyopathyACCF/AHA201110Guidelines on the Management of Cardiovascular Diseases During PregnancyESC201111Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and Prevention of ThrombosisACCP201212Guidelines on the Management of Valvular Heart DiseaseESC/EACTS201213Guideline for the Management of Heart FailureACCF/AHA201314Guideline for the Management of Patients With Atrial FibrillationAHA/ACC/HRS201415ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; AF, atrial fibrillation; AHA, American Heart Association; ASE, American Society of Echocardiography; EACTS, European Association for Cardio-Thoracic Surgery; EAE, European Association of Echocardiography; ESC, European Society of Cardiology; and VHD, valvular heart disease.2. General Principles2.1. Evaluation of the Patient With Suspected VHDPatients with VHD may present with a heart murmur, symptoms, or incidental findings of valvular abnormalities on chest imaging or noninvasive testing. Irrespective of the presentation, all patients with known or suspected VHD should undergo an initial meticulous history and physical examination. A careful history is of great importance in the evaluation of patients with VHD, because decisions about treatment are based on the presence or absence of symptoms. Due to the slow, progressive nature of many valve lesions, patients may not recognize symptoms because they may have gradually limited their daily activity levels. A detailed physical examination should be performed to diagnose and assess the severity of valve lesions based on a compilation of all findings made by inspection, palpation, and auscultation. The use of an electrocardiogram (ECG) to confirm heart rhythm and use of a chest x-ray to assess the presence or absence of pulmonary congestion and other lung pathology may be helpful in the initial assessment of patients with known or suspected VHD. A comprehensive transthoracic echocardiogram (TTE) with 2–dimensional (2D) imaging and Doppler interrogation should then be performed to correlate findings with initial impressions based on the initial clinical evaluation. The TTE will also be able to provide additional information, such as the effect of the valve lesion on the cardiac chambers and great vessels, and to assess for other concomitant valve lesions. Other ancillary testing such as transesophageal echocardiography (TEE), computed tomography (CT) or cardiac magnetic resonance (CMR) imaging, stress testing, and diagnostic hemodynamic cardiac catheterization may be required to determine the optimal treatment for a patient with VHD. An evaluation of the possible surgical risk for each individual patient should be performed if intervention is contemplated, as well as other contributing factors such as the presence and extent of comorbidities and frailty. Follow-up of these patients is important and should consist of an annual history and physical examination in most stable patients. An evaluation of the patient may be necessary sooner than annually if there is a change in the patient’s symptoms. In some valve lesions, there may be unpredictable adverse consequences on the left ventricle in the absence of symptoms necessitating more frequent follow-up. The frequency of repeat testing, such as echocardiography, will be dependent on the severity of the valve lesion and its effect on the left or right ventricle, coupled with the known natural history of the valve lesion.2.2. Definitions of Severity of Valve DiseaseClassification of the severity of valve lesions should be based on multiple criteria, including the initial findings on the physical examination, which should then be correlated with data from a comprehensive TTE. Intervention should primarily be performed on patients with severe VHD in addition to other criteria outlined in this document.This document provides a classification of the progression of VHD with 4 stages (A to D) similar to that proposed by the “2013 ACCF/AHA Guideline for the Management of Heart Failure.” Indication for intervention in patients with VHD is dependent on 1) the presence or absence of symptoms; 2) the severity of VHD; 3) the response of the left and/or right ventricle to the volume or pressure overload caused by VHD; 4) the effect on the pulmonary or systemic circulation; and 5) a change in heart rhythm. The