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Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
Evidence-Based Management of Valvular Heart Disease
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Evidence-Based Management of Valvular Heart Disease

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  • 1. Evidence-Based Management of Valvular Heart Disease Robert O. Bonow, M.D. Bluhm Cardiovascular Institute Northwestern Memorial Hospital Northwestern University Feinberg School of Medicine Consultant: Edwards Lifesciences Cardiology 2008: Innovations & Challenges
  • 2. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES 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 Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society of Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons WRITING COMMITTEE MEMBERS Robert O. Bonow, MD, FACC, FAHA, Chair Blase A. Carabello, MD, FACC, FAHA Bruce Whitney Lytle, MD, FACC Kanu Chatterjee, MD, FACC, FAHA Rick A. Nishimura, MD, FACC, FAHA Antonio C. De Leon, Jr, MD, FACC, FAHA Patrick T. O’Gara, MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA Robert A. O’Rourke, MD, MACC, FAHA Michael D. Freed, MD, FACC, FAHA Catherine M. Otto. MD, FACC, FAHA William H. Gaasch, MD, FACC, FAHA Pravin M. Shah, MD, MACC, FAHA Jack A. Shanewise, MD www.acc.org www.americanheart.org
  • 3. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Bicuspid valves with aortic root dilatation </li></ul><ul><li>Endocarditis prophylaxis </li></ul>Key recommendations:
  • 4. Mitral Regurgitation Mitral regurgitation Severe Regurgitant volume (ml) &gt; 60 Regurgitant fraction (%) &gt; 50 Regurgitant orifice (cm 2 ) &gt; 0.4
  • 5. Aortic Stenosis Aortic stenosis Severe Jet velocity (m/sec) &gt;4.0 Mean gradient (mmHg) &gt;40 Valve area (cm 2 ) &lt;1.0 Valve area (cm 2 /m 2 ) &lt;0.6
  • 6. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Mitral regurgitation and aortic stenosis: <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Bicuspid valves with aortic root dilatation </li></ul><ul><li>Endocarditis prophylaxis </li></ul>
  • 7. Chronic Severe Mitral Regurgitation - 2006 <ul><li>Indications for operation: </li></ul><ul><li>Symptoms class I </li></ul><ul><li>LV systolic dysfunction class I </li></ul><ul><li>• EF &lt;60% or serial  EF </li></ul><ul><li>• LVSD &gt;40mm or serial  ESD </li></ul><ul><li>Pulmonary Hypertension class IIa </li></ul><ul><li>RV dysfunction class IIa </li></ul><ul><li>Atrial fibrillation class IIa </li></ul><ul><li>Severe MR with repair feasible? </li></ul>ACC/AHA Guidelines 2006
  • 8. Procedures Society of Thoracic Surgeons Database, 2005 MV Repair MV Replacement 5000 0 Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 4000 3000 2000 1000 2003 Contemporary Use of Mitral Valve Repair
  • 9. <ul><li>Should all asymptomatic patients </li></ul><ul><li>with chronic severe MR undergo </li></ul><ul><li>mitral valve repair? </li></ul>… if you are certain it will be repaired?
  • 10. Mitral Regurgitation Survival of Patients With Flail Leaflets Time (years) Survival (percent) Observed from Ling et al, N Engl J Med 1996 55% Expected
  • 11. <ul><li>456 patients with MR </li></ul><ul><li>Evaluated 1991-2000 </li></ul><ul><li>Initially asymptomatic with normal LVEF </li></ul><ul><li>Management by individual patient’s physician </li></ul><ul><li>Follow-up information collected in 2002 </li></ul>
  • 12. Cardiac Survival (%) from Sarano et al. N Engl J Med 2005;352:875-883 0 1 2 3 4 5 Mitral Regurgitation Natural History of Asymptomatic Chronic MR Time (years) ERO 20-39 mm 2 ERO &lt;20 mm 2 ERO &gt; 40 mm 2
  • 13. Valvular Heart Disease Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation Raphael Rosenhek, MD; Florian Rader, MD; Ursala Klaar, MD; Harald Gabriel, MD; Marcel Krejc, PhD; Daniel Kalbeck, PhD; Michael Schemper, PhD; Gerald Maurer, MD; Helmut Baumgartner, MD Circulation 2006;113:2238-2244 41 patients with events: 21 symptoms 10 LV criteria 10 PA criteria 7 Atrial fibrillation 1 SBE 2 deaths in patients who refused surgery <ul><li>132 patients </li></ul><ul><li>62 month follow-up </li></ul><ul><li>Indications for surgery: </li></ul><ul><li>Symptoms </li></ul><ul><li>LV dilatation (ESD &gt;45mm) </li></ul><ul><li>LV dysfunction (EF &lt;60%) </li></ul><ul><li>Atrial fibrillation </li></ul><ul><li>PA pressure &gt; 50 mmHg </li></ul>
  • 14. from Rosen et al. Am J Cardiol 1994; 74: 374-380 Sarano et al. N Engl J Med 2005;352:875-883 Rosenhek et al. Circulation 2006;113:2238-2244 0 1 2 3 4 5 6 7 8 9 10 Mitral Regurgitation Natural History of Asymptomatic Severe MR Time (years) Rosen Rosenhek * Sarano Alive, Asymptomatic without Surgery (%)
  • 15. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease ACC/AHA TASK FORCE REPORT www.acc.org www.amaericanheart.org Chronic Mitral Regurgitation www.acc.org www.americanheart.org Class IIa Class I Indications for surgery: MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved LV function in whom the likelihood of successful repair without residual MR is greater than 90%. MV repair is recommended over MV replacement in the majority of patients who require surgery, and patients should be referred to surgical centers experienced in MV repair.
  • 16. Cardiovascular Surgery Influence of Hospital Procedural Volume on Care Process and Mortality for Patients Undergoing Elective Surgery for Mitral Regurgitation James S. Gammie, MD; Sean O’Brien, PhD; Bartley P. Griffith, MD; T. Bruce Ferguson, MD; Eric D. Peterson, MD Circulation 2007;115:881-887 STS Database 2000-2003 13,674 patients 575 NA hospitals
  • 17. <ul><li>19 criteria for best practice: </li></ul><ul><li>Surgical training </li></ul><ul><li>Intraoperative echocardiography </li></ul><ul><li>Volume thresholds </li></ul><ul><li>Audit </li></ul><ul><li>Cardiology and imaging </li></ul>Surgeon: &gt;25/yr Hospital: &gt;50/yr Operative mortality &lt;1% 5 year reoperation &lt;5% INTERVENTIONAL CARDIOLOGY AND SURGERY Mitral repair best practice: proposed standards B Bridgewater, T Hooper, C Munsch, S Hunter, U von Oppell, S Livesty, B Keogh, F Wells, M Patrick, J Kneeshaw, J Chambers, N Masani, S Ray Heart 2006;92:939-944
  • 18. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Mitral regurgitation and aortic stenosis: <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Bicuspid valves with aortic root dilatation </li></ul><ul><li>Endocarditis prophylaxis </li></ul>
  • 19. Carpentier’s Functional Classification Type IIIb Carpentier. J Thorac Cardiovasc Surg 1983;86:323-337 Restricted Leaflet Motion
  • 20. Time (years) Survival (percent) 0 1 p=0.001 Effect of MR on Survival Post-MI 2 3 4 5 Ischemic MR Grigioni et al. Circulation 2001;103:1759-1764 61% 47% 29% ERO = 0 ERO 1-19 ERO ≥ 20 100 80 60 40 20 0
  • 21. Time (years) Onset of Heart Failure (%) 0 1 p=0.001 Development of Heart Failure 2 3 4 5 Ischemic MR Grigioni et al. Circulation 2001;103:1759-1764 68% 46% 18% ERO = 0 ERO 1-19 ERO ≥ 20 100 80 60 40 20 0
  • 22. Ischemic Mitral Regurgitation <ul><li>Should it be repaired ? </li></ul><ul><li>Moderate MR in a patient </li></ul><ul><li>undergoing CABG ? </li></ul><ul><li>How should it be repaired </li></ul><ul><li>(or replaced)? </li></ul>
  • 23. Ischemic Mitral Regurgitation Moderate MR in a CABG patient <ul><li>Untreated MR persists and often progresses </li></ul><ul><li>Even moderate MR has a poor prognosis </li></ul><ul><li>in a patient undergoing CABG </li></ul><ul><li>Late survival and functional class are more </li></ul><ul><li>favorable with CABG plus mitral repair </li></ul>Unlike repair of myxomatous MR, recurrent ischemic MR is common … compared to CAGB alone … compared to CABG plus MVR
  • 24. 7.3.1. Mitral Valve Repair www.acc.org www.americanheart.org 3.6.5. Ischemic Mitral Regurgitation ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease ACC/AHA TASK FORCE REPORT www.acc.org www.amaericanheart.org CABG alone is usually insufficient and leaves many patients with significant residual MR, and these patients would benefit from concomitant MV repair at the time of CABG. 7.3.1.3. Ischemic Mitral Valve Disease: When functional MR is severe, it may be corrected by placement of an annuloplasty ring that decreases annular circumference, shortens the intertrigonal distance, reduces the septal-lateral annular diameter and restores the geometry of the annulus,thereby allowing the leaflets to coapt.
  • 25. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Mitral regurgitation and aortic stenosis: <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Bicuspid valves with aortic root dilatation </li></ul><ul><li>Endocarditis prophylaxis </li></ul>
  • 26. Aortic Stenosis <ul><li>Aortic valve replacement: </li></ul><ul><li>• Improves symptoms </li></ul><ul><li>• Improves LV function </li></ul><ul><li>• Improves survival </li></ul>Symptomatic Patients
  • 27. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Severe Aortic Stenosis Indications for aortic valve replacement: • Symptomatic patients • Patients undergoing CABG or surgery on the aorta or another valve • Patients with LV systolic dysfunction class I class I class I
  • 28. Aortic Stenosis Are asymptomatic patients really asymptomatic?
  • 29. Aortic Stenosis Predictive Value of Exercise Testing Symptom-Free Survival (percent) No symptoms n=79 Limiting symptoms n=46 p&lt;0.001 Time (months) Das et al Eur Heart J 2005;26:1309-1313
  • 30. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease ACC/AHA TASK FORCE REPORT www.acc.org www.amaericanheart.org Aortic Stenosis www.acc.org www.americanheart.org Class IIb Class IIb Exercise Testing: Exercise testing in asymptomatic patients with AS may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses. Indications for Aortic Valve Replacement: AVR may be considered for asymptomatic patients with severe AS and abnormal exercise response (e.g., development of symptoms or asymptomatic hypotension).
  • 31. Aortic Stenosis Are asymptomatic patients at risk of sudden death?
  • 32. Sudden Death in Asymptomatic Aortic Stenosis Follow-up SD without n (years) symptoms Chizner 1980 8 5.7 0 Turina 1987 17 2.0 0 Horstkötte 1988 35 “years” 3 Kelley 1988 51 1.5 0 Faggiano 1992 37 2.0 0 Otto 1997 123 2.5 0 Rosenhek 2000 106 2.3 1 Amato 2001 66 1.3 4 Das 2005 125 1.0 0 Pellikka 2005 622 5.4 11 Total 1190 3.7 19
  • 33. Natural History of Asymptomatic AS from Otto et al. Circulation 1997;95:2262-2270 Vmax &gt; 4.0 Vmax &lt; 3.0 Vmax 3.0 - 4.0 n=123 Age 63  16 Time (years) Asymptomatic without AVR (%) 0 1 2 3 4 5
  • 34. Natural History of Asymptomatic AS Time (years) Asymptomatic without AVR (%) Otto Rosenhek 0 1 2 3 4 5 Patients with Severe AS (Vmax &gt;4 m/s) from Otto et al. Circulation 1997;95:2262-2270 Rosenhek et al. N Engl J Med 2000;343:611 Pellikka et al. Circulation 2005;111:3290-2395 Pellikka
  • 35. Moderate or severe calcification No or mild calcification p&lt;0.001 Time (years) Asymptomatic without AVR (%) Severe AS Natural History of Asymptomatic AS Rosenhek et al. N Engl J Med 2000;343:611
  • 36. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease ACC/AHA TASK FORCE REPORT www.acc.org www.amaericanheart.org Aortic Stenosis Class IIb <ul><li>Indications for Aortic Valve Replacement: </li></ul><ul><li>AVR may be considered for adults with severe asymptomatic AS if there is a high likelihood of rapid progression (age, calcification, and CAD) or if surgery might be delayed at the time of symptom onset. </li></ul>
  • 37. <ul><li>Average hospital mortality: 8.8% </li></ul><ul><ul><li>• Low volume centers 13.0% </li></ul></ul><ul><ul><li>• High volume centers 6.0% </li></ul></ul>Goodney et al, Ann Thorac Surg 2003;76:1131-1337 Aortic Valve Replacement Hospital Mortality Data from national Medicare database 1994-1999 684 hospitals 142,488 AVRs Medicare data
  • 38. Identifying Risk of AVR <ul><li>STS risk calculator </li></ul><ul><li>24 variables </li></ul><ul><li>validated in 210,000 patients </li></ul><ul><li>www.sts.org </li></ul><ul><li>euroSCORE </li></ul><ul><li>17 variables </li></ul><ul><li>validated in &gt;500,000 patients </li></ul><ul><li>www.euroscore.org </li></ul>Shroyer et al. Ann Thorac Surg 2003;75:1856-1865 Nashef et al. Eur J Cardiovasc Surg 1999;16:9-13 Ambler et al. Circulation 2005;112:224-231 <ul><li>Valve-specific risk calculator </li></ul><ul><li>13 variables </li></ul><ul><li>validated in &gt;16,000 patients </li></ul>
  • 39. Conclusion Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.
  • 40. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Mitral regurgitation and aortic stenosis: <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Bicuspid valves with aortic root dilatation </li></ul><ul><li>Endocarditis prophylaxis </li></ul>
  • 41. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease ACC/AHA TASK FORCE REPORT www.acc.org www.americanheart.org www.acc.org www.americanheart.org Bicuspid Aortic Valve <ul><li>Indications for surgery: </li></ul><ul><li>Aortic root dilatation </li></ul><ul><li>Ao diameter &gt;50 mm or </li></ul><ul><li>rate of increase &gt;5 mm/yr </li></ul><ul><li>Patients with criteria for AVR </li></ul><ul><li>Ao diameter &gt;45 mm </li></ul>class I class I
  • 42. Journal of the American College of Cardiology @ 2006 byt the American College of Cardiology and the American Heart Association, Inc. Published by Elsevier, Inc. Vol. 48, No. 3, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.05.021 ACC/AHA PRACTICE GUIDELINES ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease Mitral regurgitation and aortic stenosis: <ul><li>Quantification of valve severity </li></ul><ul><li>Indications for mitral valve repair </li></ul><ul><li>Ischemic mitral regurgitation </li></ul><ul><li>Indications for aortic valve replacement </li></ul><ul><li>Low gradient, low output aortic stenosis </li></ul><ul><li>Selection of aortic valve prostheses </li></ul><ul><li>Endocarditis prophylaxis </li></ul>
  • 43. <ul><li>No randomized trials </li></ul><ul><li>Few observational studies </li></ul><ul><li>… some positive </li></ul><ul><li>… most negative </li></ul><ul><li>Lots of “expert” opinion </li></ul><ul><li>No cost-effectiveness studies </li></ul>Endocarditis Prophylaxis: Does It Make Sense?
  • 44. Endocarditis Prophylaxis: Does It Make Sense? Risk of endocarditis versus Risk from endocarditis
  • 45. AHA Guideline Prevention of Infectious Endocarditis Guidelines From the American Heart Association A Guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group Walter Wilson MD, Chair; Kathryn A. Taubert, PhD, FAHA; Michael Green, MD, FAHA; Peter B. Lockhart, DDS; Larry M. Baddour MD; Matthew Levison, MD; Ann Bolger, MD, FAHA; Christopher H. Cabell, MD, MHS; Masato Takahashi, MD, FAHA; Robert S. Baltimore, MD; Jane W. Newburger, MD; MPH, FAHA; Brian L. Strom, MD; Lloyd Y. Tani, MD; Michael Gerber, MD; Robert O. Bonow, MD, FAHA; Thomas Pallasch, DDS, MS; Stanford T. Shulman, MD, FAHA; Anne H. Rowley, MD; Jane C. Burns, MD; Patricia Ferrien, MD; Timothy Gardner, MD, FAHA; David Goff, MD, PhD, FAHA; David T. Durack, MD, PhD Circulation 2007;116:1736-1754 www.americanheart.org
  • 46. Indications for antibiotic prophylaxis <ul><li>Patients with: </li></ul><ul><li>Prosthetic heart valves </li></ul><ul><li>Previous infectious endocarditis </li></ul><ul><li>Cyanotic congenital heart disease </li></ul><ul><li>Congenital heart disease with indwelling shunts </li></ul><ul><li>Cardiac transplantation with valvular abnormalities </li></ul>www.americanheart.org AHA Guideline Prevention of Infectious Endocarditis Guidelines From the American Heart Association

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