Training/PracticeContemporary Issues in Cardiology PracticeHeart Valve Clinic: Rationale and Organization
Section snippets
Rationale and Challenges in Current Services
The growing burden of VHD in Western countries represents a major challenge in terms of short- and long-term monitoring and management. Despite good access to medical care in most industrialized regions and well-defined guidelines, appropriate detection and follow-up strategies are poorly applied in VHD. As proof, data from the Euro Heart Survey have shown a significant gap between guidelines and clinical practice in VHD.2 In many countries, VHD is managed by nonexperts in VHD, which may result
Main Objectives of the HVC
The HVC provides help in verifying the diagnosis, optimizing medical treatment and monitoring, assisting general cardiologists in clinical decision making, determining the correct timing and type of intervention, referring to the most suitable surgeon, assessing results after intervention, and informing and educating patients to motivate them to take their prescribed medications and look out for signs indicating a worsening of their disease (Table 1). Additional scopes of the HVC include (1)
Organization and Structure
The HVC is a modern “multidisciplinary” clinic involving health care professionals with a high degree of expertise in VHD. In Europe and North America, the most common HVC model is organized as a consulting cardiologist/nurse–based clinic that forms the basis for the standard and advanced HVC structure (Fig 1). In both models, the cardiologist is responsible for (1) the initial evaluation and monitoring of patients with VHD, (2) writing the report, (3) communication with the referring parties,
Patients Suitable for the HVC
The vast majority of patients with VHD are suitable for investigation in the HVC. Regardless of the symptomatic status, appropriate patients are (1) those with moderate or severe native valve regurgitation, (2) those with moderate or severe native valve stenosis, (3) those who have had valve repair, (4) those who have had valve replacement, (5) those who have had endocarditis, (6) those with aortic dilatation, (7) those who have had post-percutaneous valve implantation, (8) those who have had
Qualification and Training for Experts in HVC
To date, there is no established formal certification to build or work in a HVC structure. The actors involved in the HVC should be specifically educated in VHD problems and obtain all competencies, skills, and experience for the diagnosis, management, and surveillance of patients with VHD. Ideally, the cardiologist running the HVC should have been trained in a centre specializing in VHD and should acquire all the expertise for planning additional tests and referring the patient for treatment
Examinations Required Within the HVC
The initial management of patients with VHD is typically dictated by the symptomatic status. In asymptomatic patients or those with equivocal symptoms, an exercise test is systematically programmed because formally revealed symptoms are an indication for surgery. Exercise tests are performed in every new patient with significant valve disease and thereafter on an annual basis for patients remaining asymptomatic. Exercise stress echocardiography may also complement the conventional exercise test
HVC: Current Evidence
There is not yet evidence from randomized trials that HVCs are better or more cost-effective than standard care in VHD, but validation data are accumulating quickly. In degenerative mitral regurgitation, the “wait for symptoms” approach is a safe strategy when carried out in an HVC.4 Surveillance in an HVC seems to also improve adherence to guidelines and reduce unwarranted echocardiography.3 When followed in an HVC, patients with asymptomatic severe aortic stenosis report the occurrence of
HVC: Role in the Health Care Environment
The rationale for basic and advanced HVCs is well established. It may have beneficial effects at different levels:
- 1.
In the centre where an HVC is established, quality of care will be more standardized, and this may lead to improved outcomes in this centre. In fact, because of the high volume of patients, subtle differences among similar patients will be easier to identify, which will allow physicians to more appropriately select the best treatment modalities.
- 2.
An HVC may also help to enhance the
Conclusions
There is growing evidence that the organization of care for VHD requires well-identified structures specifically dedicated to VHD, namely, the HVC. The aim of the HVC is to provide highly organized services articulated around a multidisciplinary approach and delivered by experts in VHD. Several national and international medical organizations now strongly recommend the large-scale adoption of HVCs.
Funding Sources
Dr Pibarot is the Canada Research Chair in Valvular Heart Disease supported by the Canadian Institutes of Health Research (CIHR) (Ottawa, Ontario, Canada) and his research program is funded by CIHR and Heart and Stroke Foundation of Québec(Montreal, Québec, Canada).
Disclosures
The authors have no conflicts of interest to disclose.
References (5)
- et al.
ESC Working Group on Valvular Heart Disease position paper—heart valve clinics: organization, structure, and experiences
Eur Heart J
(2013) - et al.
A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on valvular heart disease
Eur Heart J
(2003)
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