Several factors contribute to this treatment delay, including low patient awareness of the symptoms of valve disease, poor detection rates within primary care, limited access to diagnostic echocardiography, delayed referral to Heart Valve Clinics or Heart Centres, and prolonged waiting lists for surgical or transcatheter intervention.4–7 The prevalence of AS increases with age and typical symptoms, including breathlessness and dizziness, may be misinterpreted by primary care physicians as general signs of ageing rather than red flags for severe AS.6,8 In Europe, many patients are unable to access regular stethoscope checks to identify severe AS before the onset of symptoms, while one in five patients with symptomatic severe AS who require treatment according to guideline recommendations do not proceed to intervention (with adverse impact on survival).5,7,9 High-quality echocardiographic imaging, an essential tool for accurate diagnosis of severe AS,10 may not be accessible in all regions and is applied to varying standards.
Solutions to these issues are key to establishing more effective treatment pathways for patients with AS. In this supplement, three articles describe the evolution and development of an optimised transcatheter aortic valve implantation (TAVI) treatment pathway, whose use in eligible patients would overcome many of these barriers. In each, the authors highlight practical steps that can be incorporated into local healthcare systems to facilitate and accelerate treatment.
In the first article, Eltchaninoff et al. describe the epidemiology of AS and evolution of its treatment, from surgical aortic valve replacement (SAVR) established in the 1960s to minimally invasive surgery and TAVI. While SAVR remains the treatment of choice for most low-risk, younger patients, TAVI has revolutionised AS treatment in those ineligible for surgery or at high surgical risk, and its use has recently expanded to intermediate- and lower-risk patients.9,11,12
In the second article, Delgado et al. emphasise how education to increase awareness of AS symptoms and improve auscultation competencies within primary care can facilitate early detection and referral. A standardised network, comprising primary care physicians, Heart Valve Clinics, Heart Centres and the Heart Team, is also described, which can be leveraged to improve all aspects of the treatment pathway. Clear communication between referring physicians, the Heart Valve Clinic and Heart Valve Centre is key to success of the pathway, particularly in relation to diagnosis, imaging, treatment outcomes and patient monitoring.
Finally, Durand et al. discuss the practical steps required to set up a successful TAVI programme that aims to resolve AS safely and efficiently whilst enabling rapid patient discharge and minimising complication rates. In support of this approach, the authors describe evidence-based best practice that can be incorporated into local healthcare systems to improve clinical outcomes.13
Together, these articles provide physicians and healthcare workers with a practical blueprint for the development of a successful TAVI programme that can provide timely, effective and safe resolution of severe AS based on established systems and, most importantly, be adapted according to the circumstances of the local healthcare environment.
Conflicts of interest
BP has received unrestricted institutional educational and research grants from Edwards Lifesciences, and speaker/consultancy fees from Abbott, Anteris, Edwards Lifesciences, Medtronic, and Microport.
Bernard Prendergast
Guest editor
[email protected]
Definition of terms used in supplement
Heart Valve Centres are centres of excellence in the treatment of valvular heart disease (VHD) that deliver optimal quality of care which is patient-centred.
Heart Valve Clinic is a dedicated and structured outpatient clinic (Chambers 2017) aiming to provide standardised care based on guidelines. Its main function is to confirm and refine the diagnosis of heart valve disease, follow patients and determine the correct timing of referral to the appropriate Heart Team. The Heart Valve Clinic is the centre of a valve disease network initiating and coordinating care between cardiac centres, referring hospitals and the community.
Heart Team is a specialised care team in VHD that includes interventional cardiologists, cardiothoracic surgeons, imaging specialists, anesthesiologists, cardiac cath lab staff, and a cardiologist. Together, the specialised Heart Team will conduct a comprehensive evaluation to determine which procedure is the most appropriate for the patient. Nursing personnel with expertise in the care of VHD patients are an important asset to the Heart Team.
Articles in this supplement
The past, present and future of aortic stenosis treatment
A standardised network to improve the detection and referral of patients with aortic stenosis
Ensuring continuous and sustainable access to aortic stenosis treatment
References
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10. Baumgartner H, Hung J, Bermejo J et al. Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017;30:372–92. https://doi.org/10.1016/j.echo.2017.02.009
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