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Archives of cardiovascular diseases
Volume 111, n° 8-9
pages 465-469 (août 2018)
Doi : 10.1016/j.acvd.2018.03.002
Received : 25 January 2018 ;  accepted : 5 Mars 2018
Scientific editorial

Dedicated heart valve networks for improving the outcome of patients with valvular heart disease?
De l’intérêt de réseaux de soins « valve » dédiés pour améliorer le pronostic des patients porteurs de valvulopathies
 

Sylvestre Maréchaux a, b, , Pierre-Vladimir Ennezat c, Raphaelle Ashley Guerbaai d, André Vincentelli e, Franck Levy f, Christophe Tribouilloy b, g
a Centre des valvulopathies, service de cardiologie, GCS-Groupement des hôpitaux de l’institut catholique de Lille, faculté libre de médecine, université catholique de Lille, rue du Grand-But, 59160 Lomme, France 
b Inserm U1088, université de Picardie, 80054 Amiens, France 
c Service de cardiologie, CHU de Grenoble, 38700 Grenoble, France 
d Departement Public Health (DPH), faculty of medicine, university of Basel, 4056 Basel, Switzerland 
e Service de chirurgie cardiaque, CHRU de Lille, 59000 Lille, France 
f Centre cardiothoracique de Monaco, 98000 Monaco 
g Service de cardiologie B, CHU d’Amiens, 80054 Amiens, France 

Corresponding author at: Centre des valvulopathies, service de cardiologie, GCS-Groupement des hôpitaux de l’institut catholique de Lille, faculté libre de médecine, université catholique de Lille, rue du Grand-But, 59160 Lomme, France.Centre des valvulopathies, service de cardiologie, GCS-Groupement des hôpitaux de l’institut catholique de Lille, faculté libre de médecine, université catholique de Lille, rue du Grand-But, 59160 Lomme, France.

Keywords : Heart valve network, Heart valve center, Heart valve diseases, Echocardiography, Cardiovascular imaging, Surgery, Interventional cardiology, Outcome

Mots clés : Réseau « valve », Centre des valvulopathies, Maladies vasculaires cardiaques, Échocardiographie, Imagerie cardiovasculaire, Chirurgie, Cardiologie interventionnelle, Pronostic

Abbreviations : CMR, GP, HVC, HVN, LV, TAVR, VHD


The prevalence of valvular heart disease (VHD) is increasing as the result of an ageing population. The most recent EuroHeart survey on VHD underlined an important gap between guidelines on the management of patients with VHD and real-life practice [1]. Several explanations may account for this discrepancy. VHD care is not considered as a cardiology subspecialty, although patients with complex or multiple VHD along with comorbid conditions need both clinical and pathophysiological VHD expertise, multimodality imaging and a global approach.

The aim here is to underline the need for the development of dedicated heart valve networks (HVNs), where patients with VHD may be evaluated by a multidisciplinary heart valve team in a heart valve centre (HVC), as emphasized recently by the European Society of Cardiology [2, 3], in coordination with the patient's general practitioner (GP) and referring cardiologist, to improve shared decision-making. This editorial will focus on the importance of HVNs to support better prevention, symptom assessment, multimodality imaging, VHD management, percutaneous interventional procedures, therapeutic education and postoperative follow-up; also, cooperation between heart valve teams is the cornerstone of multicenter clinical research into VHD.

Are symptoms related to VHD?

In patients with severe VHD, symptom onset often indicates the need for valvular intervention (class I); thorough interrogation of patients is therefore crucial, and should combine the longitudinal findings of both the GP and the referring cardiologist.

Symptom interpretation is difficult in older people or in those with comorbid conditions, such as chronic lung disease, but this can also be the case in highly trained patients, where peripheral vasculature and muscles may compensate the central haemodynamic impact of the VHD [4]. Exercise testing, exercise stress echocardiography and cardiopulmonary exercise testing in the HVC may help to elicit symptoms and determine the severity of the VHD [5, 6, 7]. Natriuretic peptide concentrations may be an interesting adjunct to the longitudinal functional follow-up.

Multimodality imaging in the HVC

Non-invasive and non-ionizing Doppler echocardiographic imaging is key in determining a diagnosis of VHD, its mechanisms and severity, and its effects on cardiac chambers and pulmonary circulation (Figure 1). A strong knowledge of VHD pathophysiology is necessary to draw appropriate conclusions from Doppler echocardiographic findings; restrictive drug-induced VHD may be wrongly identified as rheumatic VHD if exposure to specific drugs is not considered [8]. Accurate assessment of left ventricular (LV) function is necessary, as specific LV dysfunction thresholds (LV ejection fraction<50% in case of aortic regurgitation/aortic stenosis; LV ejection fraction<60% in case of mitral regurgitation) are triggers for valvular intervention [9]. Three-dimensional echocardiography enables a reproducible assessment of LV function and volumes, with less intra- and interobserver variability, and allows the quantification of mitral regurgitation regurgitant fraction [10]. The routine use of speckle-tracking strain echocardiography in identifying subclinical LV dysfunction still needs validation in patients with VHD [11]. The systematic use of a non-image continuous Doppler probe may help to reduce the proportion of patients with paradoxical low-gradient aortic stenosis, and hence facilitate therapeutic decisions [12]. Assessment of the tricuspid valve and right ventricle is also particularly challenging, but is often overlooked by clinicians, as postoperative tricuspid regurgitation remains highly prevalent and associated with poor outcome [13]. Low-dose dobutamine challenge is of critical importance to differentiate patients with LV systolic dysfunction and true severe aortic stenosis who need valvular intervention from those who need conservative heart failure management. Echocardiographic examinations should be standardized and saved on a picture archiving and communication system (PACS), with dedicated workstations for reviewing [14], to double check reliable changes in echocardiographic variables, including aortic diameters [15].



Figure 1


Figure 1. 

The heart valve clinic (HVC) in the heart valve network.

Zoom

Transoesophageal echocardiography is often needed to complete transthoracic echocardiography evaluation in complex VHD. Three-dimensional transoesophageal echocardiography accurately identifies the location of valvular lesions, such as focal valvular prolapses or commissural fusions in mitral stenosis, and assesses the anatomical severity of valvular stenosis.

Cardiac magnetic resonance (CMR) imaging offers a complementary means of estimating VHD severity, although the lack of studies with prognostic assessment is a limitation. CMR allows assessment of the regurgitant volume and fraction of mitral or aortic regurgitation with good accuracy and better reproducibility than transthoracic echocardiography [16, 17]. CMR imaging can be useful in case of discrepancy between symptoms and severity of mitral or aortic regurgitation, especially if the echocardiography examination is inconclusive. In patients with severe aortic stenosis, the finding of late gadolinium enhancement as a result of myocardial fibrosis correlates with poor outcome [18]. T1 mapping sequences by CMR imaging may be useful in the identification of diffuse fibrosis in patients with VHD, but robust outcome data are still needed.

Increased aortic valvular calcium scoring by computed tomography helps to detect severe aortic stenosis in patients with low transaortic gradient and reduced aortic valve area [9, 19]. Cardiac computed tomography allows measurement of the aortic valve area, with a severity threshold of 1.2cm2. In patients who are candidates for transcatheter aortic valve replacement (TAVR), cardiac and angiographic computed tomography allows assessment of the outflow tract and the aorta, but also the best arterial approach.

Cardiac catheterization is considered in patients with VHD if there are discrepancies between non-invasive imaging modalities and clinical findings. Because of the stroke risk, aortic valve area derived using the Gorlin equation should only be obtained in case of significant disagreement between non-invasive imaging modalities and clinical findings. Of note, angiographic grading of mitral and aortic regurgitation is no longer recommended because of the numerous pitfalls, including inappropriate use or sizing of catheters and inadequate contrast product injection [20].

Importance of a VHD team in shared-patient decision-making

A multidisciplinary VHD team, including the referring cardiologist and GP, is necessary for agreement to be reached on surgical or percutaneous interventions (Figure 1). This provides an opportunity to discuss the optimal intervention, issues linked to the procedures and the patient's quality of life. It is important that patient preference is taken into account, especially in elderly or minimally symptomatic patients. The heart valve team can also stratify the risk of patients with VHD undergoing elective or emergent non-cardiac surgery (e.g. hip fracture), as the anticipated operative risk may be largely overestimated in routine practice.

The choice of a biological versus a mechanical prosthesis should be discussed with the patient, and anticipated in the eventuality of failed repair. The most recent TAVR registries show that non-cardiovascular mortality is high, indicating that patient referral for TAVR should be improved, to avoid futile interventions and spare healthcare costs [21]. In patients with mitral stenosis, percutaneous mitral commissurotomy is preferred to surgery, but relies on intervention feasibility and expertise [22]. Further evaluation of percutaneous procedures, such as the MitraClip device (Abbott Vascular, Santa Clara, CA, USA), is needed in primary and secondary mitral regurgitation (EVEREST trial, MITRA-FR trial), and research is ongoing into the percutaneous approach for tricuspid valve conditions.

Issues linked with infective endocarditis

Dental surveillance should be implemented every 6 months to minimize infective endocarditis risk in patients with VHD and prostheses. Identification and treatment with antibioprophylaxis of potential sources of infection (dental, enteral, nasal staphylococcus) in patients undergoing valvular interventions is essential to avoid prosthetic endocarditis in both transcatheter and surgical valve procedures [23]. The latest European Society of Cardiology and American College of Cardiology/American Heart Association recommendations regarding the diagnosis of infective endocarditis encourage the use of nuclear imaging modalities, and referral to specialists in infectious diseases and their inclusion in multidisciplinary VHD team meetings [24].

Patient follow-up after VHD correction

Although prosthetic valve or repair follow-up is performed routinely by the patient's referring cardiologist (Figure 1), complications may require follow-up at the HVC through the HVN, to improve the management of complications, such as prosthesis degeneration, pannus progression, prosthesis-patient mismatch, haemolysis, paravalvular lesion or thrombosis [25].

Importance of the HVN in addition to the HVC in the context of the French healthcare system

In France, most patients with VHD are treated by private referring cardiologists in the community. Hence, the HVC can be envisaged as support for GPs and referring cardiologists in the context of the French healthcare system. Besides the HVC, the building of an HVN is of critical importance. GPs and referring cardiologists would acquire additional specialized knowledge and education through the HVN, to help them recognize early VHD-related symptoms (written patients’ reports from the HVC, meetings and continuous medical education with cardiologists from the HVC) and to ensure adequate follow-up and monitoring [26]. Similarly, patients with VHD and their relatives would be educated specifically about symptom onset, adequate exercise and diet, including the importance of close monitoring by the GP and cardiologist [26] (Figure 1). HVN development can ensure better communication and a stronger network for patients with VHD, thereby providing a connection between HVCs, referring cardiologists and general practice, and the timely referral to the HVC of patients with VHD discharged previously into the community.

Clinical nurses may represent the cornerstone of the HVN. Training and deploying specialized clinical nurses with a background in echocardiography and VHD in HVCs would be of benefit in recognizing symptom onset and severity. Telephone-call monitoring of patients with VHD between follow-up appointments would help to prevent rapid deterioration in case of symptom onset, and could be endorsed by nurses. A direct telephone number for patients to contact specialized nurses at the HVC may be efficient for timely consultation and to provide therapeutic education. In addition to providing support and guidance to stable patients with VHD, this would be a cost-effective strategy, as patients are managed in the community. Oral anticoagulant education is important in patients with a mechanical prosthesis or atrial fibrillation, allowing self-management of international normalized ratio adjustment. This would decrease the rate of valve thrombosis and bleeding events, and avoid inappropriate anticoagulant antagonizations, bridges or switches, especially in case of invasive cardiac or extracardiac procedures. Of note, beyond the specific field of VHD, clinical nurses are likely to be key in the necessary development of telemedicine and telemonitoring.

Conclusions

The development of HVNs should be beneficial to optimize the management of patients with VHD treated surgically or non-surgically. Decision-making is increasing in complexity as a result of ageing, new developments in cardiac imaging and interventional cardiology and progress in cardiac surgery. Quality of life should be taken into account in elderly patients with VHD, as well as the patient's wishes, especially in elderly and minimally symptomatic or asymptomatic patients. An indication for percutaneous or surgical valvular procedures should be discussed by the heart valve team, including the patient's referring GP and cardiologist. The convergence of VHD cases in specialized HVCs in a HVN provides a learning opportunity for cardiology residents, and for the continuous medical education of cardiologists. The pooling of exhaustive data from these specialized centres presents an opportunity for scientific investigations (Figure 1), with the willingness to improve the management and outcomes of patients with VHD.

Disclosure of interest

The authors declare that they have no competing interest.

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