2017 ESC/EACTS Guidelines for the
management of valvular heart disease
The Task Force for 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: Helmut Baumgartner* (ESC Chairperson)
(Germany), Volkmar Falk*
1
(EACTS Chairperson) (Germany), Jeroen J. Bax
(The Netherlands), Michele De Bonis
1
(Italy), Christian Hamm (Germany),
Per Johan Holm (Sweden), Bernard Iung (France), Patrizio Lancellotti (Belgium),
Emmanuel Lansac
1
(France), Daniel Rodriguez Mu
~
noz (Spain), Raphael Rosenhek
(Austria), Johan Sjo¨gren
1
(Sweden), Pilar Tornos Mas (Spain), Alec Vahanian
(France), Thomas Walther
1
(Germany), Olaf Wendler
1
(UK), Stephan Windecker
(Switzerland), Jose Luis Zamorano (Spain)
Document Reviewers: Marco Roffi (CPG Review Coordinator) (Switzerland), Ottavio Alfieri
1
(EACTS
Review Coordinator) (Italy), Stefan Agewall (Norway), Anders Ahlsson
1
(Sweden), Emanuele Barbato
(Italy), He´ ctor Bueno (Spain), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Martin Czerny
(Germany), Victoria Delgado (The Netherlands), Donna Fitzsimons (UK), Thierry Folliguet
1
(France),
Oliver Gaemperli (Switzerland), Gilbert Habib (France), Wolfgang Harringer
1
(Germany), Michael Haude
* Corresponding authors: Helmut Baumgartner, Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster,
Albert Schweitzer Campus 1, Building A1, 48149 Muenster, Germany. Tel: þ49 251 834 6110, Fax: þ49 251 834 6109, E-mail: helmut.baumgartner@ukmuenster.de. Volkmar Falk,
Department of Cardiothoracic and Vascular Surgery, German Heart Center, Augustenburger Platz 1, D-133353 Berlin, Germany and Department of Cardiovascular Surgery,
Charite Berlin, Charite platz 1, D-10117 Berlin, Germany. Tel: þ49 30 4593 2000, Fax: þ49 30 4593 2100, E-mail: falk@dhzb.de.
ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers listed in the Appendix.
1
Representing the European Association for Cardio-Thoracic Surgery (EACTS).
ESC entities having participated in the development of this document:
Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular
Interventions (EAPCI), Heart Failure Association (HFA).
Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Valvular Heart Disease.
The 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 (journals.permissions@oxfordjournals.org).
Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available
at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do
the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities in order to manage each patient s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
The article has been co-published with permission in the European Heart Journal [10.1093/eurheartj/ehx391] on behalf of the European Society of Cardiology and European
Journal of Cardio-Thoracic Surgery [10.1093/ejcts/ezx324] on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved in respect of European Heart
Journal,
V
C
European Society of Cardiology 2017. The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can
be used when citing this article.
For permissions, please email journals.permissions@oup.com.
European Heart Journal (2017) 38, 2739–2791
ESC/EACTS GUIDELINES
doi:10.1093/eurheartj/ehx391
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(Germany), Gerhard Hindricks (Germany), Hugo A. Katus (Germany), Juhani Knuuti (Finland), Philippe
Kolh (Belgium), Christophe Leclercq (France), Theresa A. McDonagh (UK), Massimo Francesco Piepoli
(Italy), Luc A. Pierard (Belgium), Piotr Ponikowski (Poland), Giuseppe M. C. Rosano (UK/Italy), Frank
Ruschitzka (Switzerland), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (UK), Miguel Sousa-
Uva
1
(Portugal), Janina Stepinska (Poland), Giuseppe Tarantini (Italy), Didier Tche´ tche´ (France), Victor
Aboyans (CPG Supervisor) (France)
The disclosure forms of all experts involved in the development of these guidelines are available on the
ESC website http://www.escardio.org/guidelines.
For the Web Addenda which include background information and detailed discussion of the data that
have provided the basis for the recommendations see https://academic.oup.com/
eurheartj/article-lookup/doi/10.1093/eurheartj/ehx391#supplementary-data.
Online publish-ahead-of-print 26 August 2017
............................ .......................... .................. .......................... ............. ............................... ............. ............................... .........
Keywords
Guidelines
•
Valve disease
•
Valve surgery
•
Percutaneous valve intervention
•
Aortic regurgitation
•
Aortic stenosis
•
Mitral regurgitation
•
Mitral stenosis
•
Tricuspid regurgitation
•
Tricuspid stenosis
•
Prosthetic heart valves
Table of Contents
Abbreviationsandacronyms...................................... 2741
1.Preamble...................................................... 2741
2.Introduction................................................... 2743
2.1 Why do we need new guidelines on valvular heart disease? . . 2743
2.2Contentoftheseguidelines................................. 2743
2.3Newformatoftheguidelines............................... 2743
2.4Howtousetheseguidelines................................ 2743
3.Generalcomments ............................................ 2743
3.1Patientevaluation.......................................... 2743
3.1.1Echocardiography...................................... 2744
3.1.2 Other non-invasive investigations . . . . . . . . . . . . . . . . . . . . . . . 2744
3.1.2.1 Stress testing ....................................... 2744
3.1.2.2 Cardiac magnetic resonance.......................... 2745
3.1.2.3 Computed tomography .............................. 2745
3.1.2.4 Cinefluoroscopy ..................................... 2745
3.1.2.5 Biomarkers ......................................... 2745
3.1.3Invasiveinvestigations.................................. 2745
3.1.3.1 Coronary angiography ............................... 2745
3.1.3.2 Cardiac catheterization .............................. 2746
3.1.4Assessmentofcomorbidity............................. 2746
3.2Riskstratification........................................... 2746
3.3Specialconsiderationsinelderlypatients .................... 2746
3.4Endocarditisprophylaxis.................................... 2746
3.5Prophylaxisforrheumaticfever............................. 2746
3.6 Concept of the Heart Team and heart valve centres . . . . . . . . . 2746
3.7Managementofassociatedconditions....................... 2747
3.7.1Coronaryarterydisease................................ 2747
3.7.2Atrialfibrillation........................................ 2747
4.Aorticregurgitation............................................ 2748
4.1Evaluation.................................................. 2748
4.1.1Echocardiography...................................... 2748
4.1.2 Computed tomography and cardiac magnetic resonance. 2749
4.2Indicationsforintervention................................. 2749
4.3Medicaltherapy............................................ 2751
4.4Serialtesting............................................... 2751
4.5Specialpatientpopulations ................................. 2751
5.Aorticstenosis................................................. 2751
5.1Evaluation.................................................. 2751
5.1.1Echocardiography...................................... 2751
5.1.2 Additional diagnostic aspects, including assessment of
prognosticparameters ...................................... 2753
5.1.3 Diagnostic workup before transcatheter aortic valve implantation . . 2753
5.2Indicationsforintervention................................. 2754
5.2.1 Indications for intervention in symptomatic aortic stenosis . 2756
5.2.2 Choice of intervention mode in symptomatic aortic
stenosis..................................................... 2756
5.2.3Asymptomaticaorticstenosis........................... 2756
5.3Medicaltherapy............................................ 2757
5.4Serialtesting............................................... 2757
5.5Specialpatientpopulations ................................. 2758
6.Mitralregurgitation ............................................ 2758
6.1Primarymitralregurgitation................................. 2758
6.1.1Evaluation............................................. 2758
6.1.2Indicationsforintervention............................. 2760
6.1.3Medicaltherapy........................................ 2761
6.1.4Serialtesting........................................... 2761
6.2Secondarymitralregurgitation.............................. 2761
6.2.1Evaluation............................................. 2761
6.2.2Indicationsforintervention............................. 2761
6.2.3Medicaltherapy........................................ 2762
7.Mitralstenosis................................................. 2762
7.1Evaluation.................................................. 2762
7.2Indicationsforintervention................................. 2764
7.3Medicaltherapy............................................ 2764
7.4Serialtesting............................................... 2765
7.5Specialpatientpopulations ................................. 2766
8.Tricuspidregurgitation......................................... 2766
8.1Evaluation.................................................. 2766
2740 ESC/EACTS Guidelines
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8.2Indicationsforintervention................................. 2766
9.Tricuspidstenosis.............................................. 2768
9.1Evaluation.................................................. 2768
9.2Indicationsforintervention................................. 2768
9.3Medicaltherapy............................................ 2768
10. Combined and multiple valve diseases . . . . . . . . . . . . . . . . . . . . . . . . . 2769
11.Prostheticvalves.............................................. 2769
11.1Choiceofprostheticvalve................................. 2769
11.2Managementaftervalveintervention....................... 2770
11.2.1 Baseline assessment and modalities of follow-up. . . . . . . . 2770
11.2.2Antithromboticmanagement.......................... 2771
11.2.2.1 General management .............................. 2771
11.2.2.2 Target international normalized ratio................. 2771
11.2.2.3 Management of vitamin K antagonist overdose
and bleeding............................................... 2771
11.2.2.4 Combination of oral anticoagulants with antiplatelet
drugs ..................................................... 2773
11.2.2.5 Interruption of anticoagulant therapy for planned
invasive procedures......................................... 2774
11.2.3Managementofvalvethrombosis...................... 2774
11.2.4Managementofthromboembolism.................... 2777
11.2.5 Management of haemolysis and paravalvular leak . . . . . . . 2777
11.2.6 Management of bioprosthetic valve failure . . . . . . . . . . . . . 2777
11.2.7Heartfailure.......................................... 2777
12.Managementduringnon-cardiacsurgery....................... 2777
12.1Preoperativeevaluation................................... 2777
12.2Specificvalvelesions ...................................... 2778
12.2.1Aorticstenosis ....................................... 2778
12.2.2Mitralstenosis........................................ 2778
12.2.3Aorticandmitralregurgitation ........................ 2778
12.3Perioperativemonitoring.................................. 2779
13.Managementduringpregnancy................................ 2779
13.1Nativevalvedisease....................................... 2779
13.2Prostheticvalves.......................................... 2779
14. To do and not to do messages from the Guidelines. . . . . . . . . . . . . 2780
15. What is new in the 2017 Valvular Heart Disease Guidelines?. . . . 2782
16.Appendix .................................................... 2784
17.References................................................... 2785
Abbreviations and acronyms
DPm Mean transvalvular pressure gradient
2D Two-dimensional
3D Three-dimensional
ABC Age, biomarkers, clinical history
ACE Angiotensin-converting enzyme
ACS Acute coronary syndrome
ARB Angiotensin receptor blocker
AVA Aortic valve area
BAV Balloon aortic valvuloplasty
BNP B-type natriuretic peptide
BSA Body surface area
CABG Coronary artery bypass grafting
CAD Coronary artery disease
CI Contra-indication(s)
CMR Cardiovascular magnetic resonance
CPG Committee for Practice Guidelines cardiac
resynchronization therapy
CT Computed tomography
EACTS European Association for Cardio-Thoracic Surgery
ECG Electrocardiogram
EDV End-diastolic velocity
EROA Effective regurgitant orifice area
ESC European Society of Cardiology
EuroSCORE European System for Cardiac Operative
Risk Evaluation
INR International normalized ratio
IV Intravenous
LA Left atrium/left atrial
LMWH Low-molecular-weight heparin
LV Left ventricle/left ventricular
LVEDD Left ventricular end-diastolic diameter
LVEF Left ventricular ejection fraction
LVESD Left ventricular end-systolic diameter
LVOT Left ventricular outflow tract
MSCT Multislice computed tomography
NOAC Non-vitamin K antagonist oral anticoagulant
NYHA New York Heart Association
PCI Percutaneous coronary intervention
PISA Proximal isovelocity surface area
PMC Percutaneous mitral commissurotomy
RV Right ventricle/right ventricular
SAVR Surgical aortic valve replacement
SPAP Systolic pulmonary arterial pressure
STS Society of Thoracic Surgeons
SVi Stroke volume index
TAVI Transcatheter aortic valve implantation
TOE Transoesophageal echocardiography
TTE Transthoracic echocardiography
TVI Time–velocity interval
UFH Unfractionated heparin
VHD Valvular heart disease
VKA Vitamin K antagonist
V
max
Peak transvalvular velocity
1. Preamble
Guidelines summarize and evaluate available evidence with the aim of
assisting health professionals in selecting the best management strat-
egies for an individual patient with a given condition. Guidelines and
their recommendations should facilitate decision making of health pro-
fessionals in their daily practice. However, the final decisions concerning
an individual patient must be made by the responsible health professio-
nal(s) in consultation with the patient and caregiver as appropriate.
A great number of guidelines have been issued in recent
years by the European Society of Cardiology (ESC) and by the
European Association for Cardio-Thoracic Surgery (EACTS) as
well as by other societies and organisations. Because of the 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
ESC/EACTS Guidelines 2741
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website (https://www.escardio.org/Guidelines/Clinical-Practice-Guide
lines/Guidelines-development/Writing-ESC-Guidelines). ESC Guide-
lines 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 EACTS
to represent professionals involved with the medical care of patients
with this pathology. Selected experts in the field undertook a com-
prehensive review of the published evidence for management of a
given condition according to ESC Committee for Practice Guidelines
(CPG) policy and approved by the EACTS. A critical evaluation of
diagnostic and therapeutic procedures was performed, including
assessment of the risk–benefit ratio. The level of evidence and the
strength of the recommendation of particular management options
were weighed and graded according to predefined scales, as outlined
in Tables 1 and 2.
The experts of the writing and reviewing panels provided declara-
tion of interest forms for all relationships that might be perceived as
real or potential sources of conflicts of interest. These forms were
compiled into one file and can be found on the ESC website (http://
www.escardio.org/guidelines). Any changes in declarations of interest
that arise during the writing period were notified to the ESC and
EACTS and updated. The Task Force received its entire financial sup-
port from the ESC and EACTS without any involvement from the
healthcare industry.
The ESC CPG supervises and coordinates the preparation of new
Guidelines. The Committee is also responsible for the endorsement
process of these Guidelines. The ESC Guidelines undergo extensive
review by the CPG and external experts, and in this case by EACTS-
appointed experts. After appropriate revisions the Guidelines are
approved by all the experts involved in the Task Force. The finalized
document is approved by the CPG and EACTS for publication in
the European Heart Journal and in the European Journal of
Cardio-Thoracic Surgery. The Guidelines were developed after care-
ful consideration of the scientific and medical knowledge and the evi-
dence available at the time of their dating.
The task of developing ESC/EACTS Guidelines also includes the
creation of educational tools and implementation programmes for
the recommendations including condensed pocket guideline ver-
sions, summary slides, booklets with essential messages, summary
cards for non-specialists and an electronic version for digital applica-
tions (smartphones, etc.). These versions are abridged and thus, if
needed, one should always refer to the full text version, which is
freely available via the ESC website and hosted on the EHJ website.
The National Societies of the ESC are encouraged to endorse, trans-
late and implement all ESC Guidelines. Implementation programmes
are needed because it has been shown that the outcome of disease
may be favourably influenced by the thorough application of clinical
recommendations.
Table 1 Classes of recommendations
Table 2 Levels of evidence
Level of
evidence A
Data derived from multiple randomized
clinical trials or meta-analyses.
Level of
evidence B
Data derived from a single randomized
clinical trial or large non-randomized
studies.
Level of
evidence C
Consensus of opinion of the experts and/
or small studies, retrospective studies,
registries.
©ESC 2017
2742 ESC/EACTS Guidelines
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Surveys and registries are needed to verify that real-life daily prac-
tice is in keeping with what is recommended in the guidelines, thus
completing the loop between clinical research, writing of guidelines,
disseminating them and implementing them into clinical practice.
Health professionals are encouraged to take the ESC/EACTS
Guidelines fully into account when exercising their clinical judgment,
as well as in the determination and the implementation of preventive,
diagnostic or therapeutic medical strategies. However, the ESC/
EACTS Guidelines do not override in any way whatsoever the indi-
vidual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition
and in consultation with that patient or the patient’s caregiver where
appropriate and/or necessary. 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. Introduction
2.1. Why do we need new guidelines on
valvular heart disease?
Since the previous version of the guidelines on the management of
VHD was published in 2012, new evidence has accumulated, particu-
larly on percutaneous interventional techniques and on risk stratifica-
tion with regard to timing of intervention in VHD. This made a
revision of the recommendations necessary.
2.2. Content of these guidelines
Decision making in VHD involves accurate diagnosis, timing of inter-
vention, risk assessment and, based on these, selection of the
most suitable type of intervention. These guidelines focus on
acquired VHD, are oriented towards management and do not deal
with endocarditis or congenital valve disease, including pulmonary
valve disease, as separate guidelines have been published by the ESC
on these topics.
2.3. New format of the guidelines
The new guidelines have been adapted to facilitate their use in clinical
practice and to meet readers’ demands by focusing on condensed,
clearly represented recommendations. At the end of each section,
Key points summarize the essentials. Gaps in evidence are listed to pro-
pose topics for future research. The guideline document is
harmonized with the simultaneously published chapter on
VHD of the ESC Textbook of Cardiology, which is freely
available by Internet access (https://academic.oup.com/
eurheartj/article-lookup/doi/10.1093/eurheartj/ehx391#
supplementary-data). The guidelines and the textbook are com-
plementary. Background information and detailed discussion of the
data that have provided the basis for the recommendations can be
found in the relevant book chapter.
2.4 How to use these guidelines
The Committee emphasizes that many factors ultimately determine
the most appropriate treatment in individual patients within a given
community. These factors include the availability of diagnostic equip-
ment, 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, owing 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 appropriate in certain clinical circumstances.
3. General comments
The aims of the evaluation of patients with VHD are to diagnose,
quantify and assess the mechanism of VHD as well as its consequen-
ces. Decision making for intervention should be made by a ‘Heart
Team’ with a particular expertise in VHD, comprising cardiologists,
cardiac surgeons, imaging specialists, anaesthetists and, if needed, gen-
eral practitioners, geriatricians and heart failure, electrophysiology or
intensive care specialists. The ‘Heart Team’ approach is particularly
advisable in the management of high-risk patients and is also impor-
tant for other subsets, such as asymptomatic patients where the eval-
uation of valve reparability is a key component in decision making.
The essential questions in the evaluation of a patient for valvular
intervention are summarized in Table 3.
3.1 Patient evaluation
Precise evaluation of the patient’s history and symptomatic status as
well as proper physical examination, in particular auscultation and
search for heart failure signs, are crucial for the diagnosis and manage-
ment of VHD. In addition, assessment of the extracardiac condi-
tion—comorbidities and general condition—require particular
attention.
Table 3 Essential questions in the evaluation of
patients for valvular intervention
VHD = valvular heart disease.
a
Life expectancy should be estimated according to age, sex, comorbidities, and
country-specific life expectancy.
ESC/EACTS Guidelines 2743
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