ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

A. Left-sided valve disease Indicator Aortic Stenosis Mild Moderate Severe Jet velocity (m per second) Less than 3.0 3.0-4.0Greater than 4.0 Mean gradient (mm Hg)* Less than 25 25-40 Greater than 40 Valve area (cm 2 ) Greater than 1.5 1.0-1.5 Less than 1.0 Valve area index (cm 2 per m 2 ) Less than 0.6 Mitral Stenosis Mild Moderate Severe Mean gradient (mm Hg)* Less than 5 5-10 Greater than 10 Pulmonary artery systolic pressure (mm Hg) Less than 30 30-50 Greater than 50 Valve area (cm 2 ) Greater than 1.5 1.0-1.5 Less than 1.0 Aortic Regurgitation Mild Moderate Severe Qualitative Angiographic grade 1ϩ 2ϩ 3-4ϩ Color Doppler jet width Central jet, width less than 25% of LVOT Greater than mild but no signs of severe AR Central jet, width greater than 65% LVOT Doppler vena contracta width (cm) Less than 0.3 0.3-0.6Greater than 0.6 Quantitative (cath or echo) Regurgitant volume (ml per beat) Less than 30 30-59 Greater than or equal to 60 Regurgitant fraction (%) Less than 30 30-49 Greater than or equal to 50 Regurgitant orifice area (cm 2 ) Less than 0.10 0.10-0.29 Greater than or equal to 0.30 Additional essential criteria Left ventricular size Increased Mitral Regurgitation Mild Moderate Severe Qualitative Angiographic grade 1ϩ 2ϩ 3-4ϩ Color Doppler jet area Small, central jet (less than 4 cm 2 or less than 20% LA area) Signs of MR greater than mild present but no criteria for severe MR Vena contracta width greater than 0.7 cm with large central MR jet (area greater than 40% of LA area) or with a wallimpinging jet of any size, swirling in LA Doppler vena contracta width (cm) Less than 0.3 0.3-0.69Greater than or equal to 0.70 Quantitative (cath or echo) Regurgitant volume (ml per beat) Less than 30 30-59 Greater than or equal to 60 Regurgitant fraction (%) Less than 30 30-49 Greater than or equal to 50 Regurgitant orifice area (cm 2 ) Less than 0.20 0.2-0.39Greater than or equal to 0.40 Additional essential criteria Left atrial size Enlarged Left ventricular size Enlarged B. Right-sided valve disease Characteristic Severe tricuspid stenosis: Valve area less than 1.0 cm 2 Severe tricuspid regurgitation: Vena contracta width greater than 0.7 cm and systolic flow reversal in hepatic veins Severe pulmonic stenosis: Jet velocity greater than 4 m per second or maximum gradient greater than 60 mmHg Severe pulmonic regurgitation: Color jet fills outflow tract; dense continuous wave Doppler signal with a steep deceleration slope *Valve gradients are flow dependent and when used as estimates of severity of valve stenosis should be assessed with knowledge of cardiac output or forward flow across the valve.Modified from the Journal of the American Society of Echocardiography, 16, Zoghbi WA, Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography, 777-802, Copyright 2003, with permission from American Society of Echocardiography (27).AR indicates aortic regurgitation; cath, catheterization; echo, echocardiography; LA, left atrial/atruim; LVOT, left ventricular outflow tract; and MR, mitral regurgitation.Bonow et al ACC/AHA Practice Guidelines e97 Downloaded from http://ahajournals.org by on August 18, 2026 patients with acquired valvular dysfunction (e.g., rheumatic heart disease).(Level of Evidence: C) • Patients who have undergone valve repair.(Level of Evidence: C) • Patients who have hypertrophic cardiomyopathy when there is latent or resting obstruction.(Level of Evidence: C) • Patients with MVP and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography.*(Level of Evidence: C) Class III Prophylaxis against infective endocarditis is not recommended for the following patients: • Patients with isolated secundum atrial septal defect.(Level of Evidence: C) • Patients 6 or more months after successful surgical or percutaneous repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus.(Level of Evidence: C) • Patients with MVP without MR or thickened leaflets on echocardiography.*(Level of Evidence: C) • Patients with physiological, functional, or innocent heart murmurs, including patients with aortic valve sclerosis as defined by focal areas of increased echogenicity and thickening of the leaflets without restriction of motion and a peak velocity less than 2.0 m per second.(Level of Evidence: C) • Patients with echocardiographic evidence of physiologic MR in the absence of a murmur and with structurally normal valves.(Level of Evidence: C) • Patients with echocardiographic evidence of physiological TR and/or pulmonary regurgitation in the absence of a murmur and with structurally normal valves.(Level of Evidence: C) *Total children's dose should not exceed adult dose.†Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.Reprinted with permission from Dajani AS, Taubert KA, Wilson W, et al.Prevention of bacterial endocarditis: recommendations by the American Heart Association.