2 In the recently revised appropriate use criteria for echocardiography, 3 echocardiography is deemed appropriate in a variety of clinical scenarios in patients with known or suspected valvular heart disease. DOI: 10.1161/CIR.0000000000000503. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Over the last decade, there has been a shift from mechanical to bioprosthetic valve replacement. Nishimura RA, Otto CM, Bonow RO, et al. VALVULAR HEART DISEASE RATHEESH R.L 2. ASE Guidelines by Publication Date. Heart, Lung and Circulation 24:1149-61. The authors of the above article wish to inform readers that the following correction has been made post-publication: footnote ‘f’ was removed from the ‘New IIa C recommendation’ section in the ‘What is new in the 2017 Valvular Heart Disease Guidelines?’ table on page 2783. . Valvular heart disease. Keywords: Cardiomyopathy, Congenital heart disease, Heart failure, Pulmonary hypertension, Stress echo-cardiography, Stress test, Valvular heart disease From the Department of … Quick Reference. 2.Nkomo et al. 2001 Jun 1;63 (11):2201-2209. American Heart Association. Nishimura RA, Otto CM, Bonow RO, et al. Valvular Heart Disease: Review and Update. In 2017, there were 3,046 deaths due to rheumatic valvular heart disease and 24,811 deaths due to non-rheumatic valvular heart disease in the United States. | Open in … Coronary heart disease may be asymptomatic. ACC/AHA/HFSA 2017 Heart … A presentation from the Meet the Guidelines task force - Valvular heart disease session at ESC CONGRESS 2017 In order to bring you the best possible user experience, this site uses Javascript. For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA 2 DS 2-VASc score. 2020 Guideline Perspectives: Part 1. To do and not to do messages from the Guidelines 654. PubMed Article PubMed Central Google Scholar 27. Anticoagulation for atrial fibrillation: Among patients with atrial fibrillation and rheumatic mitral … 3, 4 The emergence of transcatheter aortic valve replacement (TAVR) in 2002 5 … • MVP is the most common from of valvular heart disease in the united states. •Heart failure team •ICC team •Aortovascular team •EP team •6 month TTE (if severity and mechanism has been confirmed with TEE) •Consider exercise TTE •Lower threshold for surgery if the valve is the repairable and/or the patient is suitable for MIS STS/EACTS Latin America Cardiovascular Surgery Conference 2018 12 JACC Valvular Heart Disease Hub. Valvular heart disease is any disease process involving one or more of the four valves of the heart the aortic and bicuspid valves on the left side of heart and the. 13.1 Native valve disease 2779 13.2 Prosthetic valves 2779. 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease Developed in collaboration with and endorsed by the American Association for Thoracic Surgery, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons 2017 ESC/EACTS guidelines for the management of valvular heart disease. [Real-time 3D echocardiography for estimation of severity in valvular heart disease : Impact on current guidelines]. Herz. 2017;135:e1159–e1195. Eur Heart J 2017; 38:2739. 2020 Guideline Perspectives: Part 3. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. HANEY WAHBA, M.D., Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Heart valve repair usually involves the heart valve leaflets that open and close to pump blood through the heart. Basic science studies provide further support for the concept of regional differences in the severity of aortopathy within the aorta of BAV patients. Baumgartner H, Falk V, Bax JJ, et al. 2017; 70 (2): p.252-289. Acquired heart valve disease usually affects the aortic or mitral valves. – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - id: 40c189-ODhiM 2020 Guideline Perspectives: Part 2. 2017 Dec 15;96(12):784-789. Congenital heart valve disease presents as a discrete condition or as part of a complex syndrome. This report, issued by the ACVIM Specialty of Cardiology consensus panel, revises guidelines for the diagnosis and treatment of myxomatous mitral valve disease (MMVD, also known as endocardiosis and degenerative or chronic valvular heart disease) in dogs, originally published in 2009. 2017 AMI-STEMI; 2017 Valvular Heart Diseases; 2017 Dual Antiplatelet Therapy; 2015 Infective Endocarditis; 2014 Hypertrophic Cardiomyopathy; 2013 Cardiac Pacing and Cardiac Resynchronization Therapy Download the slide sets (ppt) 2020. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease)". 2017 ESC/EACTS Guidelines for the management of valvular heart disease Eur Heart J. 2014; 129:2440–92. 2009 May;22(5):442. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. Agricola, E. et al. Download PowerPoint File. Share Echo assessment of aortic valve disease Echo assessment of aortic valve disease Read more ... (based on 2014 AHA/ACC Valvular heart disease guideline) 15. Appendix 658. Valvular Heart Disease with Causes Test and Nursing. These guidelines were updated in 2017 to reflect the remarkable increase in the use of percutaneous valvular devices, information regarding anticoagulation usage, and when to intervene. 1. These clinical practice guidelines were issued in 2017 and will be reviewed in 4 years (2021) or earlier depending on the availability of new evidence. This article seeks to provide recommendations based on the optimal balance of these competing factors. Pheochromocytoma. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. These items break the guidelines down into easy-to-use summaries. He has co-authored the American Heart Association/American College of Cardiology Guidelines for the Treatment of Valvular Disease from 1998-2017. Guideline for resuscitation in cardiac arrest after cardiac surgery 15 What is new in the 2017 Valvular Heart Disease Guidelines? What is new in the 2017 Valvular Heart Disease Guidelines? 21. 2021. of Medicine College of Medicine Pamantasan Ng Lungsod Ng Maynila Cardiac valves Anatomy There are 4 cardiac valves 2 semilunar valves_ aortic and pulmonic 2 AV valves _ mitral and tricuspid. 1 Patients with VHD and certain comorbid conditions or prosthetic heart valves (PHVs) are at high risk for thromboembolic complications and often require antithrombotic therapy (Table 53–1). The management of exercising individuals with valvular … Congenital heart disease is a large, rapidly emerging global problem in child health. Rheumatic heart disease treatment guidelines. Discussion. rheumatic valvular heart disease 101 Summary 105 References 105 13. New European guidelines on the management of valvular heart disease—supported by the European Society of Cardiology (ESC) and European Association of CardioThoracic Surgery (EACTS)—were recently published. Circulation. artificial heart valves with the European Heart Association guidelines for 2017. 2012. This slide set was adapted from the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (Journal of the American College of Cardiology). By summarising current guidelines and highlighting areas that remain controversial, we hope we provided a comprehensive overview of the modern and yet evolving role of TOE in general cardiology. American Heart Association. Interventions (EAPCI), Heart Failure Association (HFA). Otto CM, Nishimura RA, Bonow RO, et al. Management of Patients With Valvular Heart Disease, Journal of the American College of Cardiology (2014), doi: 10.1016/j.jacc.2014.02.536. Oct. 02, 2017 Download Like Liked. 15. Published on April 28, 2017, available at: Yancy, et. American College of Cardiology. We conducted a case-control study. N Engl J Med 1997; 337:32-41. Eligible patients were those admitted in the cardiology or the cardiac surgery units of our hospital between January, 1 st 2003 and June 30 th 2009, with mitral insufficiency diagnostic codes (ICD-10 I340 and I051). Eur. References 2785. Eur Heart J2017; 38: 2739-91. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. disease. Aetiology Rheumatic disease is the principal cause (in countries where disease is common) Mitral valve prolapse Dilatation of the LV and mitral valve ring (e.g. 2. Eur J Cardiothorac Surg. November 15, 2017 Volume 96, Number 10 ... American Heart Association guidelines. J Heart Valve Dis. J Thorac Cardiovasc Surg 2016;151(4):959–66. References 659. References. It is an implanted device which is increasingly adopted by patients suffering from valvular heart disease. The transmitral gradient is under strong influence from heart rate and forward blood flow. Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart (the aortic and mitral valves on the left side of heart and the pulmonic and tricuspid valves on the right side of heart). Valvular Heart Disease and the Cardiac Exam 2009 Tricuspid Valve Disease Tricuspid stenosis is rare Associated with rheumatic heart disease TR usually occurs ... – A free PowerPoint PPT presentation (displayed as a Flash slide show) on PowerShow.com - id: 462ce2-NDk1M 5,6 (Figure 1. Peak transvalvular velocity measurement 16. ### Learning objectives Valvular heart disease (VHD) is an important cause of morbidity and mortality whose prevalence is set to increase dramatically as a consequence of the increase in life expectancy in middle-income and high-income nations. ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Download as PowerPoint. Bernardo D. Morantte Jr. M.D. This paper summarizes these recommendations. Link Google Scholar; 10. Neonatal And Maternal Outcomes In Pregnant Women With Cardiac. The valve is in the ‘surgeon's view’ orientation with the heart tilted to the left. 2010. doi: 10.1093/eurheartj/ehx391 [2] The European Society of Cardiology/European Association of Cardiothoracic Surgery (ESC/EACTS) valve disease management guidelines 2 recommend stress echocardiography and intervention in patients with abnormal exercise stress tests response and severe aortic stenosis (AS) or significant mitral stenosis (MS) (Class I). Valvular heart disease is a common disorder seen by hospitalists. AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non–ST-Elevation Myocardial Infarction. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. ... Valvular heart disease. "ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. The worldwide burden of valvular heart disease (VHD) continues to grow as a result of increases in life expectancy combined with the high incidence of rheumatic heart disease in developing nations. Although these guidelines are very comprehensive, these typically are not very inviting to read. EACTS guidelines for the use of patient safety checklists. Valvular Heart Disease Dr . Guidelines for management of Mitral Regurgitation ACC/AHA 2014 guidelines for management of valvular heart disease. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. doi: 10.1016/j.jacc.2017.03.011 . 16. It may feel heavy or like someone is squeezing the heart. Nearly 25,000 deaths in the U.S. each year are due to heart valve disease from causes other than rheumatic disease. Valvular heart disease affects 1%–2% of young individuals, many of whom aspire to partake in competitive sport or high intensity recreational exercise. Without the ability to substantially alter the prevalence of congenital heart disease, interventions and resources must be used to improve survival and quality of life. Heart J. Primary & Secondary Prevention of Cardiovascular Disease 2017. Abbreviations and acronyms Our Patient 4.3 m/sec 43 mm Hg 0.18 0.6 cm2 0.3 cm 2/m 3.1 m/sec 26 mm Hg 0.26 0.3 cm /m AORTIC STENOSIS 2014 ACC/AHA Valvular Heart Disease Guidelines Low LVEF Low Gradient AS Normal LVEF (b) The mitral valve leaflets, each of which usually consists of three discrete segments or scallops.These are designated A1, A2, and A3 for the anterior leaflet and P1, P2, and P3 for the posterior leaflet. Transcatheter aortic valve replacement: 2015 in review. Prosthetic heart valve market - Prosthetic heart valve market, Size, Share, Market Intelligence, Company Profiles, Market Trends, Strategy, Analysis, Forecast 2017-2022 HEART VALVE MARKET INSIGHTS Heart valve market is expected to grow significantly at a CAGR of 11.8% during 2017-2022. Peak transvalvular velocity 18. Thromboembolic complications of valvular heart disease are often devastating. 28. Abbreviations and acronyms Eur Heart J 2017; 38: 2739−2791. 2020 Executive Summary. rheumatic valvular heart disease 101 Summary 105 References 105 13. Valvular Heart Disease. Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary. Cardiac magnetic resonance imaging (MRI) and echocardiography are noninvasive imaging modalities that are of paramount importance in daily clinical practice for diagnosis, prognosis, and treatment planning in patients with left-sided valvular heart disease (VHD). Infective endocarditis Wikipedia. 2. the improvement and standardization of the management of patients suffering from coronary artery disease. These guidelines were updated in 2017 to reflect the remarkable increase in the use of percutaneous valvular devices, information regarding anticoagulation usage, and when to intervene. Clinical Practice Guidelines and scientific statements of the ESC are prepared by a task force of cardiologists, an ad hoc group commissioned by the ESC Clinical Practice Guidelines Committee and approved by the ESC Board. Patients … ESC Clinical Practice Guidelines aim to present all the relevant evidence to help physicians weigh the benefits and risks of a particular diagnostic or therapeutic procedure on Valvular Heart Disease. American College of Cardiology. Valvular Heart Disease. Explore the latest in valvular heart disease, including advances in diagnosis and management of mitral and aortic valve disease, TAVR, and more. 2017 Valvular Heart Disease Guideline Writing Committee Rick A. Nishimura, MD, MACC, FAHA, Co-Chair Catherine M. Otto, MD, FACC, FAHA, Co-Chair *Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. 17. 2014; 129: … This manuscript reviews the most recent European and American guidelines related to exercise and sport participation in individuals with valvular heart disease (VHD) and identifies areas not addressed by these guidelines. Indian J Anaesth 2017;61:721-7. Although valvular heart disease (VHD) is less common in industrialized countries than coronary artery disease (CAD), heart failure (HF), or hypertension, guidelines are of interest in this field because VHD is frequent and often requires intervention. Class I (strong) Benefit ⋙ Risk. 2017;135(25):e1159–e1195. doi: 10.1016/j.jtcvs.2015.12.001 (Epub 2015 Dec 9). 2017 ESC/EACTS Guidelines for the management of valvular heart disease. 2782. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Methods. 5. The development of this document avoided these disagreements, with all parties having equal voice. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Background: Valvular heart disease (VHD) is an important cause of mortality and morbidity and has been subject to important changes in management. According to the 2014 valvular heart disease guidelines and the 2017 guideline update, they consider MS to be very severe if MVA less than or equal to 1 cm squared, and severe if … The guidelines are published on a regular basis in the European Heart Journal. Nishimura RA, Otto CM, Bonow RO, et al. Echocardiography plays a major role in diagnosis and assessment of severity and prognosis. The National Burden of Disease Study in early 2000s showed that coronary artery disease (CAD) and cerebrovascular disease (CVA) are the top two causes of death for both men and women. Expert Consensus Document. Nishimura RA, Otto CM, Bonow RO, Carabello BA, et al. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. We not only give you tips to lead a life free of heart ailments but also help you to connect with the best doctors and heart surgeons and specialists in Hyderabad with a click of a button. Valvular Heart Disease. This update on the evaluation of valvular regurgitation is a comprehensive review of the noninvasive assessment of valvular regurgitation with echocardiography and CMR in the adult. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European … While there is no cure for valvular heart disease, there are many treatments as well as many steps you can take to manage your condition. If your valvular heart disease is mild, you may not need treatment for many years. Baumgartner H, Falk V, Bax JJ, et al. The 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines provide information on valvular heart disease diagnosis and treatment. The most frequent heart diseases in children were congenital heart disease (20/59, 34%), valvular heart disease (12/59, 20%), with 5/12 (42%) fulfilling the criteria for rheumatic heart disease, dilated cardiomyopathy (9/59, 15%), and right heart failure due to pulmonal hypertension (7/59, 12%). Congenital Heart Disease Guidelines. Interventional procedures for adult structural heart disease. Valvular heart disease (VHD) is frequent is industrialized countries and its prevalence increases with age due to the predominance of degenerative aetiology. The 2006 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the treatment of valvular heart disease (VHD) were notable for the paucity (0.3%) of the recommendations supported by a level of evidence A—that is, evidence supported by two or more randomized controlled trials (RCTs). 2. The past 15 years have brought a remarkable improvement in the clinical outcome of patients with valvular heart disease… 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease… Valvular Heart Disease Ssu PPT. ... TIA, transient ischemic attack; TTE, transthoracic echocardiography; VARC, Valvular Academic Research Consortium; VIV: valve-in-valve; VHD, valvular heart disease; VKA, vitamin K antagonist Vmax; ... guidelines active viral disease. Circulation. Mitral Regurgitation in Patients with Advanced Systolic Heart Failure, J of Cardiac Failure, 2004. Cardiovascular Disease Assessment In Pregnant And Postpartum Women. As a leading researcher in valvular heart disease, Dr. Carabello has published more than 250 peer-reviewed research studies and 200 book chapters and editorials. Prospects for a streptococcal vaccine 106 Early attempts at human immunization 106 M-protein vaccines in the era of molecular biology 106 Immunization approaches not based on streptococcal M-protein 107 Antithrombotic therapy can reduce the risk of thromboembolism, but at the cost of increased bleeding. Am Fam Physician. Congenital heart valve disease often involves the aortic or pulmonary valves that do not develop properly. Harjai KJ et al. Valvular Heart Diseases Can Take The Form Of Stenosis, Insufficiency (regurgitation), PPT. Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Valvular Heart Disease. [Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis. STEMI / NSTEMI Guidelines. 12. Clinical approach is paramount for evaluation of the patient’s history, symptoms and for the detection of VHD by auscultation. This was supplemented by a search of the Cochrane database and the National Guideline Clearinghouse. 13.1 Native valve disease 652 13.2 Prosthetic valves 653. The 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines provide information on valvular heart disease diagnosis and treatment. Ppt Heart Disease In Pregnancy Powerpoint Presentation Id 5077605. Severe valvular heart disease was defined as follows: aortic stenosis, mean gradient >40 mm Hg; mitral stenosis, valve area ≤1.5 cm 2 or mean gradient >5 mm Hg; and aortic and primary mitral regurgitations, classified as severe according to echocardiographic criteria. 17. There are limited reports on the impact of intensive physical activity on the progression of valvular heart disease; therefore, current recommendations are based on consensus opinion. Valvular heart disease can be caused by congenital or acquired etiology. Executive Summary. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Valve structure: AV _ papillary muscle, chordae, leaflets Left Heart The worldwide burden of valvular heart disease (VHD) continues to grow as a result of increases in life expectancy combined with the high incidence of rheumatic heart disease in developing nations. Nishimura RA, et al. Nishimura RA, et al. A bifid P wave as seen on the ECG in mitral stenosis. Rheumatic feverRheumatic fever (RF) is generally classified as aconnective tissue or collagen-vascular diseaseIt is an inflammatory reaction that causes damage tocollagen fibrils and to the ground substance ofconnective tissueInvolves multiple organs: primarily the heart, thejoints, and the central nervous systemRecurrent attacks of RF may cause fibrosis of heartvalves, leading to chronic valvular heart disease. 1-3 The most common types of left-sided VHD in the Western world are aortic valve stenosis (AS), aortic valve regurgitation … Among these, aortic and mitional balbial diseases indicate 99% of confirmed pathologies and mortality. Adult Congenital Heart Disease; Atrial Fibrillation Hiratzka LF, Creager MA, Isselbacher EM, Svensson LG. March 24, 2017. Infective endocarditis guidelines 2017 pdf Valvular heart disease (VHD) exists at ≈2.5% of the general U.S. population, prevalence increases to 11.7% >75 years.1 Valve-disease-related deaths account for 1.9% of total U.S. deaths. The pain is felt when the heart is not getting enough blood or oxygen. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease. Paul A, Das S. Valvular heart disease and anaesthesia. 2020 Data Supplements (.zip file) 2020 Pocket Guide. We conducted systematic reviews to synthesize. (a) AC, anterior commissure; PC, posterior commissure. Gooley R et al. Introduction. Description: 2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (2014 Guideline with 2017 Focused Update Incorporated) Date: March 15, 2017 8/5/2015 16 17. [Article in German] Buck T(1), Bösche L(2), Plicht B(3). [Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 1. recommendations for active primary prevention of coronary artery disease and its risk factors. The VHD II survey was designed by the EURObservational Research Programme of the European Society of Cardiology to analyze actual management of VHD and to compare practice with guidelines. New Frontiers in Valvular Heart Disease Transcatheter interventions for mitral and tricuspid valve disease show promise, but are still in early development. [Eur Heart J (2017) 38(36): 2739–2786]. Class IIa (moderate) Benefit … Degenerative valve disease (DVD) usually affecting the mitral valve is the most common cardiac disease in dogs being responsible for 75–80% of all cardiac disease. 7 (6): 672–707. Circulation. 4. ... valvular disease, congenital heart disease, and … 656. P mitrale (left atrial hypertrophy) P pulmonale (right atrial hypertrophy) Retrograde P wave Atrial fibrillation. The use of echocardiography is a Class 1 indication for the evaluation of many clinical scenarios in which valvular heart disease is suspected. Elsevier, 2014. STENOSIS Valve orifice is smaller, impending the forward flow of blood and creating a pressure gradient difference across an open valve 4. Dept. Eur Heart J 2017;38(36):2739–2791. Prospects for a streptococcal vaccine 106 Early attempts at human immunization 106 M-protein vaccines in the era of molecular biology 106 Immunization approaches not based on streptococcal M-protein 107

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