Valvular Heart Disease: A Companion to Braunwald's Heart Disease: Expert Consult - Online and Print

Front Cover
Inside front cover
Front Matter
	Valvular Heart Disease A Companion to Braunwald\'s Heart Disease FIFTH EDITION
Copyright
Contributors
Foreword
Preface
Acknowledgments
Braunwald\'s heart disease family of books
Table of Contents
1 Epidemiology of valvular heart disease
	Key points
	Incidence and prevalence of valve disease
		Valve disease in industrially underdeveloped areas
			Incidence of rheumatic fever and chronic rheumatic disease
			Prevalence of rheumatic disease
		Valve disease in industrially developed areas
	Causes of valve disease
		Rheumatic fever
		Endomyocardial fibrosis
		Calcific aortic stenosis
		Mitral prolapse
		Secondary mitral regurgitation
		Secondary aortic regurgitation resulting from aortic dilation
		Secondary tricuspid regurgitation
		Infective endocarditis
		Replacement heart valves
		Congenital conditions
		Systemic inflammatory conditions
		Carcinoid, drugs, and radiation
			Carcinoid
			Drugs
			Radiation
	Disease by valve type
		Aortic stenosis and regurgitation
		Mitral stenosis
		Mitral regurgitation
		Right-sided valve disease
		Tricuspid valve disease
		Pulmonary valve disease
		Multiple valve disease
	Conclusions
	References
2 Three-dimensional anatomy of the aortic and mitral valves
	Key points
	Mitral valve
		Mitral valve anatomy
			Mitral valve annulus
			Mitral valve leaflets
			Mitral valve commissures
			Mitral valve chordae
			Papillary muscles
		3DE and mitral valve apparatus
		3DE imaging
			Image acquisition
			Image display
		3DE mechanisms of mitral valve dysfunction
			Degenerative mitral valve disease
			Ischemic mitral regurgitation
				Mitral leaflet tethering in ischemic mitral regurgitation.
				Mitral valve annulus in ischemic mitral regurgitation.
				Leaflet growth in ischemic mitral regurgitation.
				Treatment of ischemic mitral regurgitation.
		3DE quantification of mitral regurgitation
			3D vena contracta area
			3D proximal isovelocity surface area
			3D anatomic regurgitant orifice area
			3D mitral inflow and left ventricular outflow tract stroke volume
			Limitations of 3D-derived quantitative measurements for mitral regurgitation
		Mitral stenosis
	Aortic valve
		Aortic valve anatomy
			Aortic valve cusps
			Aortic valve annulus
			Aortic root complex
		Aortic valve physiology
		3DE imaging
			Image acquisition
			Image display
		Roles for 3DE
			Aortic valve anatomy
				Native valves.
				Prosthetic valves.
				Endocarditis.
			Aortic stenosis assessment
				Left ventricular outflow tract.
				Stroke volume quantification.
				Aortic valve planimetry.
			Transcatheter aortic valve replacement
				Preprocedure: Aortic root assessment.
				Periprocedure.
				Postprocedure.
			Aortic regurgitation assessment
				Classification.
				Vena contracta.
				Stroke volume.
	Aortic-mitral valve interactions
	Conclusions
	References
3 Molecular mechanisms of calcific aortic valve disease
	Key points
	Background
		The normal aortic valve
		General concepts
		Experimental models
	Initiation phase
		Lipid deposition
		Inflammation
		Angiogenesis
		Matrix remodeling and fibrosis
			Angiotensin II
			Valve interstitial cell and matrix interaction
	Propagation phase
		Bone morphogenetic protein signaling
		WNT/β-catenin signaling
		Transforming growth factor-β signaling
		RANK, RANKL, and osteoprotegerin
		Ectonucleotidases and matrix vesicles
		Cell death as a contributor to non-osteogenic calcification
	Additional modulators of osteogenic activity
		Direct inhibitors of osteogenic signaling
			SMAD6
			Matrix GLA protein
		Oxidative stress
		Nitric oxide signaling
		Peroxisome proliferator–activated receptor-γ signaling
		NOTCH1/cadherin 11 signaling
		Galectin 3
		Dipeptidyl peptidase 4 inhibition
		Fetuin-A
		Epigenetic regulation of osteogenic signaling
	Summary of molecular mechanisms in the valve
	Myocardial response to pressure overload
		Left ventricular hypertrophy
		Diffuse interstitial fibrosis
		Cell death and replacement fibrosis
		Transition to heart failure
	Translation to therapeutic interventions and future directions
	Conclusions
	Acknowledgments
	References
4 Clinical and genetic risk factors for calcific valve disease
	Key points
	Calcific aortic valve disease
		Clinical risk factors
			Older age
			Male sex
			Race and ethnicity
			Cigarette smoking
			Blood pressure, hypertension, and vascular stiffness
			Dyslipidemia and lipoprotein(a)
			Diabetes, obesity, and the metabolic syndrome
			Chronic kidney disease and mineral metabolism
			Osteoporosis and bone metabolism
			Aortic valve calcium
			Multiple risk factors and risk scores
		Genetic factors
			Heritability
			Mendelian disorders of calcific aortic stenosis
			Candidate genes for calcific aortic stenosis
			Genome-wide association studies and mendelian randomization
	Mitral annular calcification
		Risk factors
		Genetic factors
	Summary
	References
5 Left ventricular and vascular changes in valvular heart disease
	Key points
	Left ventricular hemodynamics: Pressure-volume loops
	Left ventricular hypertrophic remodeling
	Changes to the left ventricle with left-sided valve disease
		Aortic stenosis
			Pressure overload
			Effects on left ventricular remodeling and function
		Mitral regurgitation
			Volume overload
			Effects on left ventricular remodeling and function
		Aortic regurgitation: Mixed pressure and volume overload
	Vascular properties and load
		Pulmonary vascular changes
		Systemic vascular changes
	References
6 Principles of medical therapy for patients with valvular heart disease
	Key points
	The heart valve clinic
	Diagnosis of valve disease
	Preventive measures
		Diagnosis and prevention of rheumatic fever
		Prevention of infective endocarditis
		Prevention of embolic events
			Native valve disease with atrial fibrillation
			Other indications for anticoagulation
			Anticoagulation clinics
			General health maintenance
	Monitoring disease progression
	Medical therapy
		Prevention of progressive valve disease
		Prevention of left ventricular contractile dysfunction
		Prevention of left atrial enlargement and atrial fibrillation
		Prevention of pulmonary hypertension
		Symptoms caused by valve disease
	Management of concurrent cardiovascular conditions
		Hypertension
		Coronary artery disease
		Aortic disease
		Arrhythmias
		Heart failure
	Noncardiac surgery in patients with valve disease
	Patient education
	References
7 Surgical and procedural risk assessment of patients with valvular heart disease
	Key points
	Risk algorithms
		Goals
		Construction of risk models
		Limitations
		Clinical utility
		Predicted outcomes
	Risk algorithms for surgical aortic valve replacement
		Logistic EuroSCORE
		STS-PROM risk model
	Risk algorithms for transcatheter aortic valve implantation
		German Aortic Valve Score
		FRANCE 2 risk model
		TAVI2-SCORe
		OBSERVANT risk model
		CoreValve U.S. risk score
		STS/ACC TVT risk model
	Frailty and procedural assessment
	Integrative approach
	References
8 Imaging the aortic valve
	Key points
	Imaging aortic valve anatomy
		Normal anatomy of the aortic valve and aortic root
			Echocardiography of normal aortic valve anatomy
			Cross-sectional imaging of normal aortic valves
		Congenitally abnormal anatomy of the aortic valve
	Aortic stenosis severity
		Echocardiography
			Direct visualization and planimetry
			Velocity and pressure gradients
			Valve area by the continuity equation
			Other echocardiographic measures of stenosis severity
		Cardiac catheterization
		Gated computed tomography angiography
		Cardiac magnetic resonance imaging
	Aortic regurgitation severity
		Echocardiography
			Color doppler parameters
			Pulsed-wave doppler
			Continuous-wave doppler
			Quantitative assessment
			Regurgitation quantitation by 3D echocardiography
		Cardiac catheterization
		Computed tomography
		Cardiac magnetic resonance imaging
	Assessment of pathophysiology
		Aortic stenosis
		Aortic regurgitation
		Left ventricular volumes and size
			Linear measurements
			Volumetric measurements
		Measures of ventricular function
			Global left ventricular systolic function
			Left ventricular mass
			Cardiac magnetic resonance for evaluating left ventricular response to aortic valve disease
	References
9 Aortic stenosis: Clinical presentation, disease stages, and timing of intervention
	Key points
	Stages of disease
	Etiology
	Clinical presentation
		Clinical history
		Physical examination
	Evaluation
		Echocardiography
		Cardiac catheterization
		Stress testing
		Exercise treadmill stress testing
		Low-dose dobutamine stress echocardiography
		Computed tomography
		Biomarkers
	Clinical course
		At risk for aortic stenosis (stage A)
		Progressive mild to moderate aortic stenosis (stage B)
		Asymptomatic severe aortic stenosis (stage C)
		Symptomatic severe aortic stenosis (stage D)
			Sudden death
			Heart failure
			Atrial fibrillation
			Other
	Medical therapy
		Prevention of disease progression
		Comorbid conditions
		Periodic monitoring
		Exercise limitations
		Noncardiac surgery
	Aortic valve replacement
		Timing of intervention
			Symptomatic severe aortic stenosis (stage D1)
			Asymptomatic severe aortic stenosis (stage C)
			Low-flow, low-gradient aortic stenosis with reduced ejection fraction (stage D2)
			Low-flow, low-gradient aortic stenosis with preserved ejection fraction (stage D3)
			Undergoing cardiac surgery
		Choice of valve
		Outcomes after aortic valve replacement
			Clinical outcomes
			Hemodynamic outcomes
	Palliative care
	References
10 Aortic regurgitation: Clinical Presentation, Disease Stages, and Management
	Key points
	Etiology
	Acute aortic regurgitation
		Diagnosis
		Pathophysiology
		Management
	Chronic aortic regurgitation
		Clinical presentation
			Clinical history
			Physical examination
			Electrocardiography and chest radiography
			Echocardiography
			Other imaging modalities
				Cardiac magnetic resonance.
				Cardiac computed tomography.
				Radionuclide angiography.
			Exercise testing
		Disease stages
			Pathophysiology
			Aortic regurgitation progression
				Normal left ventricular systolic function.
				Left ventricular systolic dysfunction.
		Medical management
			Vasodilator therapy
			Endocarditis prevention
		Serial evaluations
		Indications for surgery
			Aortic valve replacement or repair
			Concomitant disease of the ascending aorta and aortic root
	References
11 The bicuspid aortic valve and associated aortic disease
	Key points
	Prevalence
	Etiology
		Embryology
		Genetics
	Clinical phenotype
		Valve anatomy
		Associated cardiovascular lesions
			Coarctation of the aorta
			Turner syndrome
			Coronary artery anomalies
			Other congenital heart malformations
		Aortopathy
			Pathophysiology
			Histopathology
			Ascending aortic dilation
	Clinical presentation and diagnosis
		Physical examination
		Transthoracic echocardiography
		Transesophageal echocardiography
		Other tomographic imaging
	Overall disease course
	Valvular complications
		Aortic stenosis
		Aortic regurgitation
		Infective endocarditis
	Aortic complications
		Progressive aortic dilation
		Risk of aortic dissection
		Late aortic complications after aortic valve replacement
	Recommendations for treating bicuspid aortic valve patients
	Surgical treatment of the bicuspid aortic valve and ascending aorta
	Pregnancy in patients with a bicuspid aortic valve
	References
12 Transcatheter aortic valve replacement: Indications, procedure, and outcomes
	Key points
	Percutaneous aortic valve designs
		Balloon-expandable valves
		Self-expanding valves
		Other valve systems
	Randomized TAVR trials
		Partner
		Corevalve U.S. pivotal trial
		Partner 2
		Sapien 3 intermediate-risk registry
		Surtavi
		Reprise III
		Portico
		TAVR in patients at low surgical risk
	Findings from TAVR registries
		U.K. TAVI registry
		U.S. TVT registry
	TAVR guidelines
		Patient selection
		Complications and management
		Postprocedural care
	State-of-the-art TAVR
	Ancillary devices used in TAVR
		Cerebral embolic protection
		Vascular closure devices
	Expanding clinical indications
		Valve-in-valve procedures
		Bicuspid aortic valve disease
		Low-flow aortic stenosis
		Moderate aortic stenosis with left ventricular dysfunction
		Asymptomatic severe aortic stenosis
	Alternatives to TAVR
		Surgical aortic valve replacement
		Balloon aortic valvuloplasty
	Conclusions
	References
13 Imaging assessment for transcatheter aortic valve replacement
	Key points
	Preprocedural cardiac imaging
		General principles
			Echocardiography
			Computed tomography
			Magnetic resonance imaging
		Annular and aortic root assessment
			Computed tomography
			Echocardiography
			Magnetic resonance imaging
			Novel techniques
		Peripheral and central vascular access
			Computed tomography
			Magnetic resonance imaging
			Novel techniques
		Additional case planning
			Prediction of delivery angles
			Embolic protection planning
			Coronary artery and bypass graft analysis
			Emergency surgical planning
			Left atrial appendage thrombus
	Technical considerations
		Computed tomography
		Magnetic resonance imaging
	Preprocedural noncardiovascular imaging
	Periprocedural evaluation
		Immediate preprocedural evaluation
		Periprocedural guidance considerations
		Immediate postprocedural evaluation
	Postprocedural monitoring
		Postprocedural valve assessment
		Replacement valve durability
		Postprocedural evaluation for cerebrovascular events
	Future directions
	References
14 Surgical approach to diseases of the aortic valve and aortic root
	Key points
	Approaches to the aortic valve and root
		Median sternotomy
		Minimally invasive approaches
			Upper hemisternotomy
			Right anterior thoracotomy
	Aortic valve replacement
		Bioprosthetic valves: Stented
		Sutureless valves
		Bioprosthetic valves: Stentless
		Mechanical valves
		Aortic homografts
		Ross procedure
		Guidelines for valve choice
	Aortic valve repair
	Risks of aortic valve surgery
	Aortic root surgery
		Indications
		Aortic root replacement with composite valve-graft: Modified bentall procedure
		Valve-sparing aortic root replacement: David and Yacoub procedures
			Yacoub procedure
			David procedure
		Aortic root enlargement
	Special challenges
		Aortic dissection
		Aortic valve replacement after previous coronary artery bypass graft
		Aortic valve replacement after previous aortic valve replacement
		Failed aortic root replacement
		Porcelain aorta
	Future perspectives
		New bioprosthetic leaflet technology
		Non-warfarin therapy for mechanical valves
	Conclusions
	References
15 Diagnostic evaluation of mitral regurgitation
	Key points
	Imaging mitral valve anatomy
		Valve leaflets
		Mitral annulus
			Dilation
			Calcification
		Chordae tendineae
		Papillary muscles
		Left ventricular dysfunction
	Echocardiographic evaluation of mitral regurgitation
		Jet origin and direction
		Regurgitant volume
		Vena contracta
		Proximal isovelocity surface area method
		Supportive evidence for mitral regurgitant severity
	Challenging issues in evaluation of mitral regurgitation
		Dynamic changes in mitral regurgitation severity
		Role of exercise echocardiography
		Quantitation of secondary mitral regurgitation
	Imaging the left ventricle
		Pathophysiology
		Assessment of myocardial contractility
		End-systolic volume
		Left atrial compliance
	Evaluation of mitral regurgitation in patients undergoing transcatheter interventions
		Preprocedural evaluation
		Postprocedural evaluation
	Other imaging approaches
		Cardiac magnetic resonance
		Cardiac computed tomography
		Left ventricular angiography
	References
16 Rheumatic and calcific mitral stenosis and mitral commissurotomy
	Key points
	Epidemiology
	Pathophysiology
		Mechanisms of valve obstruction
		Hemodynamic consequences of mitral stenosis
			Mitral gradient
			Left atrium
			Pulmonary circulation
			Right heart
			Left ventricle
		Exercise physiology
	Clinical presentation
		History
		Physical examination
		Chest radiography and electrocardiography
		Echocardiography
			Assessment of severity
			Assessment of valve morphology
			Consequences of mitral stenosis
			Mitral regurgitation
			Associated lesions
			Thromboembolic risk
		Stress testing
		Cardiac computed tomography
		Cardiac catheterization
	Natural history
		Onset and progression of valvular lesions
		Clinical outcome without intervention
		Complications
	Medical therapy
		Prevention of rheumatic fever and infective endocarditis
		Treatment of symptoms
		Prevention of thromboembolism
		Modalities of follow-up
	Interventions for mitral stenosis
		Surgical commissurotomy
		Balloon mitral commissurotomy
			Patient selection
			Technique
			Monitoring the procedure and assessing immediate results
			Immediate results
				Efficacy.
				Failures.
				Risks.
				Predictors of immediate results.
			Long-term results
				Predictors of long-term results.
			Applications of balloon mitral commissurotomy in special patient groups
				After surgical commissurotomy.
				Patients for whom surgery poses a high risk.
		Surgical mitral valve replacement
		Transcatheter prosthesis implantation
	Treatment strategy
		Rheumatic mitral stenosis
		Calcific mitral stenosis
	References
17 Mitral valve prolapse
	Key points
	Definition and anatomy
	Pathogenesis
	Natural history
		Prevalence
		Prognosis for mitral valve prolapse
		Mortality, atrial fibrillation, and heart failure risks
		Arrhythmias and risk of sudden death
		Infective endocarditis
	Echocardiographic evaluation
		Assessment of regurgitant severity
		Assessment of mitral regurgitation effects
		Morphologic assessment of the valve
	Management and timing of intervention
		Class I or iia indications for intervention
		Evaluation of asymptomatic patients and identification of high-risk subsets
		Management of asymptomatic patients
		Follow-up of conservatively managed patients
	Summary
	References
18 Secondary (functional) mitral regurgitation in ischemic and dilated cardiomyopathy
	Key points
	Definition
	Epidemiology
	Mechanism
		Ischemic mitral regurgitation
		Functional mitral regurgitation in the absence of coronary artery disease
	Diagnosis
		Echocardiography
		Grading mitral regurgitation severity by echocardiography
		Quantitative parameters
		Integration of multiple parameters
		Dynamic nature of mitral regurgitation
		Value of exercise testing
	Prognosis
	Treatment
		Medical therapy
		Cardiac resynchronization therapy
		Coronary revascularization
		Surgical treatment of functional mitral regurgitation
		Surgical mitral valve repair versus replacement
		Transcatheter mitral valve therapies
		Spectrum of functional mitral regurgitation
	Conclusions
	References
19 Surgical mitral valve repair and replacement
	Key points
	Surgical anatomy of the mitral valve
		Mitral annulus
		Mitral leaflets and commissures
		Chordae tendineae
		Papillary muscles and the left ventricle
	Pathophysiologic triad of mitral valve regurgitation
		Dysfunction
		Etiology and lesions
	Mitral valve surgery
		Surgical approach
		Mitral valve repair
		Mitral valve replacement
	Outcomes of mitral valve repair
		Degenerative mitral valve disease
		Ischemic mitral regurgitation
		Rheumatic valve disease
	Outcomes of mitral valve replacement
	References
20 Transcatheter mitral valve repair and replacement
	Key points
	Rationale for transcatheter therapy
	Classification of percutaneous repair techniques
		Leaflet and chordal technology
			Mitraclip
			Other devices
		Indirect annuloplasty
		Direct annuloplasty and hybrid techniques
		Left ventricular remodeling techniques
	Transcatheter mitral valve replacement
	Conclusions
	References
21 Imaging guidance of transcatheter mitral valve procedures
	Key points
	Basic principles
		Types of transcatheter mitral valve intervention
		Goals of imaging guidance
		Education and training for procedural imaging
	Key steps for imaging guidance
		Standard imaging tools
			X-ray imaging
			Two- and three-dimensional echocardiography
			Intracardiac echocardiography
			Cardiac magnetic resonance imaging
			Multislice computed tomography
		Advanced imaging tools
			Echocardiographic-fluoroscopic fusion imaging
			Overlay of computed tomography and fluoroscopy
			Mitral valve 3d modeling
			Rapid prototyping
	General approach
		Assessment of mitral valve morphology and function
		Interatrial septum puncture
		Catheters and devices
	Imaging guidance of specific transcatheter mitral valve interventions
		Balloon mitral commissurotomy
		Mitral valve edge-to-edge repair
			Preprocedural imaging planning
			Intraprocedural guidance
			Postprocedural assessment
		Paravalvular mitral prosthesis leak repair
			Preprocedural imaging planning
			Intraprocedural guidance
			Postprocedural assessment
		Transcatheter mitral valve implantation and valve-in-valve percutaneous therapy
	Conclusions and future directions
	References
22 Intraoperative echocardiography for mitral valve surgery
	Key points
	Nomenclature
	The intraoperative milieu
	Pre-bypass assessment
		Preoperative preparation
		Systematic examination
			Two-dimensional imaging
			Epicardial echocardiography
			Three-dimensional echocardiography
		Mitral regurgitant severity
			Loading conditions
			Color doppler imaging
			Vena contracta
			Spectral doppler imaging
			Reparability
				Carpentier type I: Normal leaflet motion.
				Carpentier type II: Excessive leaflet motion.
				Carpentier type IIIB: Restricted systolic leaflet motion.
				Carpentier type IIIA: Restricted systolic and diastolic leaflet motion.
		Prosthetic valves
		Tricuspid regurgitation
	Post-bypass evaluation
		Native valve assessment
		Mitral valve systolic anterior motion
		Prosthetic valve assessment
		Assessment of proximate structures
	Guidelines and outcomes
	Conclusions
	References
23 Diseases of the tricuspid valve
	Key points
	Pathophysiology of tricuspid valve disease
		Primary versus secondary tricuspid valve disease
		Response of the right heart to pressure and volume overload
		Principles of diagnosis
			Tricuspid valve stenosis and regurgitation
			Stages of tricuspid valve disease
			Assessment of right ventricular size and function
			Pulmonary artery pressures
	Tricuspid valve anatomy
		Normal anatomy and variants
		Changes in anatomy with disease states
		Imaging of tricuspid valve leaflets
	Tricuspid regurgitation
		Etiology
		Diagnosis
		Natural history
		Medical and surgical treatment
			Overview
			Indications for surgery
			Tricuspid regurgitation with left-sided valve disease
			Isolated tricuspid valve surgery
			Tricuspid valve repair versus replacement
		Specific considerations based on etiology
			Flail tricuspid valve leaflets
			Ebstein anomaly
			Carcinoid heart disease
			Secondary tricuspid regurgitation due to pulmonary thromboembolic disease or pulmonary arterial hypertension
			Pacemaker- or defibrillator-induced tricuspid regurgitation
			Tricuspid regurgitation in patients undergoing left ventricular assist device implantation
			Atrial septal defect
	Tricuspid stenosis
		Etiology
		Diagnosis
		Natural history
		Medical and surgical treatment
	Summary
	References
24 Pulmonic valve disease in adults
	Key points
	Overview of pulmonic valve disease
		Etiology
		Pathophysiology
	Pulmonic, subpulmonic, and supravalvular pulmonary stenosis
		Pulmonic valve stenosis
			Background
			Clinical presentation and assessment
			Management and outcomes
		Subpulmonic stenosis
			Background
			Clinical presentation and assessment
			Management and outcomes
		Supravalvular and peripheral pulmonary artery stenosis
			Background
			Clinical presentation and assessment
			Management and outcomes
	Tetralogy of fallot
		Background
		Surgical repair and residuae
		Clinical presentation and assessment
		Pulmonic regurgitation and timing of pulmonic valve replacement
		Pulmonic valve replacement surgery and outcomes
	Transcatheter pulmonic valve replacement
		Background
		Outcomes
		Impact on management of pulmonic valve disease
	References
25 Infective endocarditis
	Key points
	Epidemiology
	Pathogenesis
	Prevention
	Diagnosis
		Clinical manifestations
		Diagnostic criteria
		Blood cultures
		Biomarkers and polymerase chain reaction
		Transthoracic and transesophageal echocardiography
			Indications
			Echocardiographic findings
		Other imaging modalities
	Management
		Medical therapy
			Antibiotic therapy
			Anticoagulant and antiplatelet therapies
		Complications
			Valve regurgitation and heart failure
			Embolic events
			Neurologic complications
		Surgical intervention
			Indications
			Optimal timing
			Surgical approach
		Cardiac implantable electronic device removal
	Long-term prognosis and follow-up
	References
26 Prosthetic heart valves
	Key points
	Types of prosthetic heart valves
		Mechanical valves
			Durability and long-term outcomes
		Tissue valves
			Stented bioprostheses
			Stentless bioprostheses
			Homografts
			Autografts
			Transcatheter bioprostheses
		Comparison of mechanical and tissue valves
	Choice of valve procedure and prosthesis type
		Valve procedure
		Prosthetic valve type
	Medical management and surveillance after valve replacement
		Anti-thrombotic therapy
			General principles
			Interruption of anti-thrombotic therapy
		Pregnancy
		Infective endocarditis prophylaxis
		Clinical assessment
		Doppler echocardiography
	Evaluation and treatment of prosthetic valve dysfunction and complications
		Prosthesis–patient mismatch
		Structural valve deterioration
		Paravalvular leak
		Thromboembolism and bleeding
		Prosthetic valve thrombosis
		Infective endocarditis
		Hemolytic anemia
	References
27 Management of bioprosthetic valve degeneration
	Key points
	History of prosthetic heart valves
	Characteristics of bioprosthetic heart valves
	Mechanisms of failure of bioprosthetic heart valves
	Open heart surgery for bioprosthetic heart valve failure
	Transcatheter aortic valve-in-valve implantation
		Preclinical and early clinical studies
		Clinical outcomes after transcatheter aortic valve-in-valve implantation
		Valve-in-valve procedure for severe prosthesis–patient mismatch
		Persistent stenosis after aortic valve-in-valve procedures
		Clinical thrombosis of aortic valve-in-valve prostheses
		Coronary obstruction after aortic valve implantation
		Aortic valve-in-valve implantation in uncommon bioprostheses
	Future perspectives
	References
28 Valvular heart disease in pregnancy
	Key points
	Physiologic changes of pregnancy
		Normal hemodynamic changes
			Pregnancy
			Positional changes
			Peripartum and postpartum changes
		Evaluation by echocardiography
			Normal anatomic changes
			Doppler changes
	Epidemiology
	Risk factors for adverse outcomes
	Basic clinical approach
		Evaluation of disease severity
		Management during pregnancy
			Clinical monitoring
			Medical therapy
			Effects of intercurrent illness
			Heritability
		Management in the peripartum period
			Peripartum hemodynamic monitoring
			Type of delivery
		Timing of surgical intervention
	Specific valvular lesions and outcomes
		Aortic stenosis
		Mitral stenosis
		Aortic regurgitation
		Mitral regurgitation
		Right-sided valve disease
		Prosthetic valves
			Outcomes
			Anticoagulation
	References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	X
	Y
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