2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Jeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN, FAHA, Biykem Bozkurt, MD, PhD, FACC, FAHA, Ralph G. Brindis, MD, MPH, MACC, Mark A. Creager, MD, FACC, FAHA[§§][1], Lesley H. Curtis, PhD, FAHA, David DeMets, PhD,

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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk/benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk/ benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in Tables 1 and 2 .

View this table:

Table 1 
Classes of recommendations



View this table:

Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have which might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to …

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Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009)

Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009).

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https://www.nejm.org/doi/pdf/10.1056/NEJMra051091?listPDF=true

Coronary Artery Stents

OBJECTIVE—To determine the clinical features and long term prognosis of infective endocarditis in patients who were not drug addicts.
DESIGN—Prospective case series.
SETTING—A university hospital that is both a referral and a primary care centre.
PATIENTS—138 consecutive cases of infective endocarditis diagnosed and treated from January 1987 to March 1997.
RESULTS—Mean patient age was 44 (20) years old. 95 patients (69%) had native valve endocarditis and 43 (31%) had prosthetic valve endocarditis. Staphylococci were the causal microorganisms in 34% of cases and streptococci in 33%. Severe complications occurred in 83% of patients and 51% of patients underwent surgery during the active phase (22% was emergency surgery). Inpatient mortality was 21%. During a follow up of 56 (44) months, 10 patients (9%) needed late cardiac surgery and seven (5% of the whole series) died. Overall 10 year survival was 71%. There were no significant differences in survival depending on the type of treatment received during the hospital stay (medical or combined medical-surgical).
CONCLUSIONS—A high early surgery rate is related to good long term results and does not increase in-hospital mortality. Medical treatment, however, also offers favourable long term results in cases of responsive infective endocarditis where poor prognostic factors are absent.


Keywords: infective endocarditis; staphylococci; streptococci

https://heart.bmj.com/content/heartjnl/83/5/525.full.pdf

Long term outcome of infective endocarditis in patients who were not drug addicts : a 10 year study

Coronary lesions located in major bifurcations constitute a challenge for the use of stents. Although the occlusion of a side branch covered by a stent is infrequent, the maintenance of a patent, stenosis-free bifurcation may result in a complex procedure. Between September 1994 and April 1998, 70 patients were treated by stent implantation for coronary bifurcation stenosis. The side branch always had a diameter >2 mm. The pairs of treated arteries were: left anterior descending (LAD)/diagonal artery in 32 patients, circumflex/obtuse marginal in 26, right coronary/posterior descending artery in 5, and LAD/circumflex in 7. We applied 2 different techniques of stent implantation: (1) deployment of 1 stent in the parent vessel covering the takeoff of the side branch and subsequent angioplasty of the side branch across the metallic structure (group A, n = 47 patients), and (2) implantation of 1 stent at the ostium of the side branch and complete reconstruction of the entire bifurcation with additional implantation of 1 or 2 stents at the parent vessel (group B, n = 23 patients). There were no significant differences between groups at baseline variables. Procedural success was similar in both groups: 42 (89%) in group A versus 21 (91%) in group B. However, major cardiac events at 18 months follow-up were higher in group B (event-free probability 44% vs 75%, p <0.05). Selected patients with coronary stenosis at major bifurcations can be treated with an acceptable rate of primary and late success. Complex techniques providing radical stent reconstruction of the bifurcation seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation.

Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin.

Several observational studies have shown a better late outcome in patients with coronary bifurcation lesions treated with stents in whom the side branch was not stented Balloon dilation and provisional stenting for the side branch seem an attractive strategy to manage these challenging types of lesions This study evaluated the results of a three-step phase strategy in the stent treatment of bifurcated coronary lesions We treated 126 patients, 58 ± 11 years old, with major coronary bifurcation stenosis The therapeutic procedure was undertaken following three phases; progression through each phase was triggered by the failure of one procedure to achieve a <50% residual stenosis at the side branch: in the first step, balloon angioplasty of the side branch followed by stenting of the parent vessel; in the second, balloon redilation of the side-branch origin across the metallic structure of the stent; in the third, stenting of the side-branch origin Immediate success was achieved in 116 patients (92%) Angiographic results in each phase were as follows: in the first step, 35 patients (28%) had procedural success, 3 patients had failure, and 88 crossed to the next step; in the second, 76 patients (86%) had procedural success, 7 patients had failure, and 5 crossed to the next step; in the third, all 5 patients had procedural success The overall major cardiac event-free probability at 15 months was 78% Target vessel revascularization took place in 19 patients (15%) and when stratified by phases were 13% of patients treated in the first step, 16% of patients in the second step, and 20% of patients in the third step Patients with coronary stenosis at major bifurcations may be treated following an unitary stepwise approach This attitude may avoid side-branch stent implantation in most patients, providing good immediate and long-term results Cathet Cardiovasc Intervent 2002;55:50–57 © 2002 Wiley-Liss, Inc

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A stepwise strategy for the stent treatment of bifurcated coronary lesions

Objetivos El objetivo es evaluar la supervivencia y evolucion de la clase funcional y de la funcion ventricular en pacientes con insuficiencia cardiaca severa secundaria a miocardiopatia dilatada hipertensiva. Metodos Los criterios de inclusion fueron: ingreso por insuficiencia cardiaca clase III o IV, ventriculo izquierdo dilatado con fraccion de eyeccion Resultados La fraccion de eyeccion inicial fue de 30 ± 5% (20-40), y estaban en clase III el 35% y en clase IV el 65% de los pacientes. Recibieron inhibidores de la enzima conversora de la angiotensina el 100%, diureticos el 100%, betabloqueantes el 53% y calcioantagonistas el 35% de los pacientes. La supervivencia fue del 100%. La fraccion de eyeccion paso del 30 ± 5% inicial al 44 ± 11% al ano, al 50 ± 11% a los 3 anos y al 51 ± 10% al final del seguimiento (p Conclusiones La evolucion de la disfuncion ventricular severa hipertensiva es favorable a largo plazo con un correcto tratamiento (mortalidad nula, mejoria funcional y de la fraccion de eyeccion). Sin embargo, la persistencia de dilatacion ventricular indica que el dano miocardico causado por la sobrecarga cronica de presion no desaparece.

A Ramírez

Papers

Long term outcome of infective endocarditis in patients who were not drug addicts : a 10 year study

Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin.

A stepwise strategy for the stent treatment of bifurcated coronary lesions

Insuficiencia cardíaca debida a disfunción ventricular sistólica severa de origen hipertensivo. Evolución clínica y funcional a largo plazo

Manifestaciones clinicas de la endocarditis infecciosa