Centres of excellence in heart valve surgery: are there standards for best practice?

Correspondence to Professor P Lancellotti; [email protected] The growing prevalence of valvular heart disease represents a major challenge in terms of short-term and long-term management and surveillance. 2 Despite welldefined guidelines, appropriate detection and follow-up strategies are still poorly applied in valvular heart disease. 4 In many countries, valvular heart diseases are managed by non-experts in the field, which may result in misdiagnosis and lead to inappropriate delays in decisions about valve interventions, and compromise patient outcome. The establishment of multidisciplinary services delivered by experts in valvular heart disease in a well-structured environment in order to provide specialised and centralised evaluation, care and education to patients with valvular heart disease has become the basis of implementation of ‘Heart Valve Centre of Excellence’ across Europe and outside Europe. Centres with a dedicated ‘Heart Valve Clinic’ have a designed pathway to diagnose and monitor patients with valvular heart disease. They regroup a multidisciplinary team of cardiologists, nurses, radiologists, anaesthesiologists, and surgeons proficient in diagnosing and treating all cardiac valve syndromes and disorders. This involves sophisticated cardiac valve symptoms recognition, diagnostic techniques such as three-dimensional echocardiography, cardiac magnetic resonance, cardiac CT and cardiac catheterisation. The ‘Heart Valve Clinic’ also provides help in optimising and monitoring medical treatment, assisting the general cardiologists for clinical decisionmaking, determining the correct timing and type of intervention, referring the patient to the most suitable surgeon, assessing results after intervention, and informing patients to motivate them to follow their prescribed medications and be alert for signs indicating a worsening of their disease. 2 The ‘Heart Valve Clinic’ model is generally organised as a consultative cardiologist nurse-based clinic that forms the basis for the standard and advanced ‘Heart Valve Clinic’ structure. The vast majority of patients with valvular heart disease are suitable for investigation in the ‘Heart Valve Clinic’. However, prioritisation based on capacity, the degree of valvular heart disease severity, and the presence of an emergency condition might be applied. In the UK, senior nurses or sonographers are allowed to ensure surveillance and monitoring of patients with uncomplicated valve disease before and after surgery. Applying this model of care, the group of Chambers et al have shown that the proportion of patients followed up according to best practice guidelines rose (from 41% to 92%), while the total number of unwarranted echocardiograms performed fell significantly. Also, Rosenhek et al reported that the ‘wait’ for symptoms approach is a safe strategy when carried out in a ‘Heart Valve Clinic’. Surveillance in these clinics seems to also improve adherence to guidelines. However, despite this growing body of observational evidence supporting the notion that patient-centred care is best delivered within these organised structures, their adoption across Europe remains scanty, that is, 21% in the UK. Therefore, clarifying the patient outcome and the economic impact of such models of care represents a major goal for the ‘Heart Valve Community’. Outcome studies are ongoing. Several groups have merged their database, that is, the HeArt ValvE Clinic group, to enhance the clinical evidence of their usefulness. In practice, the decision to refer the patient for intervention is based on several factors: valvular heart disease severity, symptoms, degree of ventricular dysfunction, comorbidities, interventional risk, skill of the surgical/ interventional team, patient preferences, and so on. These factors are often difficult to assess, require specific training, and a high