Alec Vahanian法国巴黎Bichat医院， University Paris VII
　　The importance of a collaborative approach between cardiologists and cardiac surgeons in the management of patients with valvular heart disease (VHD) has led to the production of a joint document by the ESC (European Society of Cardiology) and EACTS ( European Association of Cardio-Thoracic Surgery).
The overall message of this document is to stress of the importance of comprehensive evaluation of the cardiac and extra-cardiac condition of the patient， constantly checking consistency between the results of diagnostic investigation and clinical findings at each step of the decision-making process.  Ideally， the decision-making process and the management of the patient should be carried out by a “heart team” with particular expertise in valve disease. This collaboration is critical particularly in high-risk patients， and the guidelines emphasize a team approach. The "heart team" should include cardiologists， cardiac surgeons， imaging specialists， anaesthetists， and other specialists if needed .
The previous guidelines were published in 2007. The main changes concerning therapeutic options for the two most frequent presentations of native valve disease are as follows:
In aortic stenosis， transcatheter aortic valve implantation (TAVI) has been introduced to the valve guidelines for the first time. TAVI is recommended only "in hospitals with cardiac surgery on-site" and with a heart team available to assess individual patient risks. TAVI is indicated in patients with severe symptomatic aortic stenosis who are judged by the heart team as unsuitable for valve replacement. TAVI should be considered for high risk patients with severe symptomatic aortic stenosis based on the individual risk profile. The guidelines emphasise that， at present， TAVI should not be performed in patients at intermediate risk for surgery， for which no supporting data are currently available.
The debate on the indications for aortic valve replacement in asymptomatic patients is ongoing. In light of recent data， surgery should be considered in patients at low operative risk， with normal exercise performance and very severe aortic stenosis or progressive disease. Surgery may also be considered in patients with markedly elevated naturietic peptide levels， significant increase of mean pressure gradient on exercise echocardiography， or excessive left ventricular hypertrophy.
In mitral regurgitation， the Guideline Taskforce has reinforced the statement that mitral valve repair should be the preferred technique when it is expected to be durable.  As a consequence， it is important to increase surgical expertise and the number of reference centres for this frequent disease.
Here again， the indications in the asymptomatic patients are still a matter of debate， but the Taskforce widened the indications and proposed that surgery should be considered in asymptomatic patients with preserved LV function， high likelihood of durable repair， low surgical risk， flail leaflet， and left ventricular end systolic diameter >40 mm. Surgery may also be considered in asymptomatic patients with primary MR in cases of severe dilatation of the left atrium or pulmonary hypertension on exercise echocardiography.
Also for the first time in the valve guidelines， the Taskforce stated that percutaneous mitral valve repair using the edge-to-edge technique may be considered in high risk or inoperable patients refractory to optimal medical management with the aim of improving symptoms. However， longer follow-up is needed as well as randomised clinical trials.
Finally， the paucity of data in the field of VHD has lead to basing most recommendations on expert consensus. Thus the Taskforce pleads for an increase in research efforts in this field.
心内科医生和心脏外科医生之间的合作在瓣膜性心脏病患者的管理中占据重要位置，这促使欧洲心脏病学学会（ESC）和欧洲心胸外科协会（EACTS）联合公布了新指南。
该指南总体上强调全面评估瓣膜性心脏病患者心脏和其他器官情况的重要性，需要在决策的每一步持续评估诊断性检查和临床表现之间是否一致。在理想情况下，决策过程和患者管理应当由具备瓣膜疾病专业知识的“心脏医疗小组”来完成。医生之间的协作是至关重要的，对高危患者尤其如此，新指南强调了团队协作的方法。“心脏小组”应当包括心内科医生、心脏外科医生、影像科医生和麻醉科医生，必要时还可以有其他医生加入。
上一版指南于2007年发表。新版指南的主要变化是针对两种最为常见的原发性瓣膜疾病的治疗选择：
主动脉瓣狭窄：经导管主动脉瓣植入术（TAVI）首次被收入指南。TAVI仅被推荐用于“有心脏外科医生的医院”和有心脏小组能够评价每例患者的风险时。TAVI被推荐用于重度主动脉瓣狭窄的患者且经心脏小组判断为不适合瓣膜置换术。基于患者的危险情况，重度症状性主动脉瓣狭窄的高危患者应该考虑TAVI。新指南强调，TAVI不应被用于外科手术中等危险的患者，因为当前没有数据支持。
有关无症状性患者主动脉瓣置换适应证还有争议。考虑到最新数据，手术低风险、运动试验正常和非常严重的主动脉瓣狭窄或疾病进展的患者应当考虑手术治疗。利钠肽水平显著升高、运动后超声心动图显示平均压力梯度显著增加或有明显左室肥厚的患者也可以考虑手术治疗。
二尖瓣关闭不全：指南工作组强调指出，如果期望瓣膜能够持久的话，应优先选择二尖瓣修复技术。因此，重要的是提升二尖瓣这一常见疾病的外科手术技能和增加治疗中心数。
对无症状患者的治疗指征同样存在争论，但是工作组扩大了适应证，建议在下述无症状患者应当考虑外科手术：左室功能正常、持久修复的可能性大、外科手术风险小、连枷样二尖瓣叶和左室收缩末期直径 > 40 mm。下述无症状原发性二尖瓣关闭不全患者也可以考虑外科手术：左房重度扩张或运动后超声心动图上可见肺动脉高压。
新指南首次提出，在高危患者或最佳药物治疗效果不好的无法手术的患者，可以考虑采用边对边技术进行经皮二尖瓣修复，目的是改善症状。但是，需要随访时间更长，也需要开展随机临床试验。
最后，瓣膜性心脏病领域数据的缺乏使得本指南中的大多数建议是基于专家共识。因此，专家组呼吁在此领域开展更多的研究。