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Fix O Cad 3055

patients with as are usually young and fit, with a median age of about 40 years and median nyha class ii symptoms. they are frequently women, and the causative organism is staphylococcus aureus, which is highly resistant to methicillin. patients often present with symptoms of exercise-induced low-gradient as, even with a high transvalvular gradient (≥40 mmhg). the left atrial pressure is usually normal, and most patients are in new york heart association class i, with no syncope. doppler echocardiography is the standard diagnostic tool; it shows a mildly restrictive or nonrestrictive lesion in the mitral orifice, with a mean transmitral gradient of <5 mmhg ( figure 6 ). in contrast, muga scintigraphy shows a maximum lv ejection fraction <60% in most patients; this finding correlates with the transmitral gradient, but is caused by the abnormal diastolic lv relaxation. preoperative muga scintigraphy can be important in planning and performing the operation, including assessment of the risk for intraoperative pacemaker placement and optimal surgical approach (i.e., anterior or lateral).

femoral access is the preferred access site in patients with severe as undergoing a valve operation, with a less than 1% risk of access-site bleeding or death in the first 30 days after the operation. successful biventricular pacing may restore a normal sinus rhythm in patients with severe as, with evidence of severe lv dysfunction and sinus bradycardia. strict adherence to the recommended intensity of exercise, close monitoring of symptoms, and heart rate, as well as in-hospital implantation of a pacemaker, should be performed, preferably before referral to a tertiary center.

most patients with valvular heart disease are cared for by cardiologists, yet the majority of valve interventions performed are cardiac surgery procedures (from incision to closure) rather than by cardiac surgeons, and the majority of valvular interventions are performed under general anesthesia. this guideline discusses in detail the evaluation and management of patients with symptomatic native or prosthetic valve regurgitation and symptomatic as. other aspects of valvular heart disease, such as congenital valve anomalies, immune-mediated disease, and active infection, will be addressed elsewhere in this guideline. the 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. 1 another full revision was made in 2014, 2 with an update in 2017. 3 there was an additional statement of clarification specifically for surgery for aortic dilation in patients with bicuspid aortic valves in 2016. 4 the present guideline will replace the 2014 guideline and 2017 focused update. 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. where applicable, sections were divided into subsections of 1) diagnosis and follow-up, 2) medical therapy, and 3) intervention. the purpose of these subsections is to categorize the class of recommendation according to the clinical decision-making pathways that caregivers use in the management of patients with vhd.
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