Summary

Newer types of valvular heart disease are becoming more and more complex necessitating a new system of care and a new type of clinic based on the hub-and-spoke model; with the GP, cardiologist, and other personnel working together to improve patient outcome.

Post-independence rheumatic heart disease (RHD) was a major public health problem in India. Chronic rheumatic valvular disease accounted for the largest number of cardiac cases (22 to 50 per cent) in India although in comparison from West the incidence of acute rheumatic fever (ARF) was comparatively low (as a matter of fact only 30% of cases gave a history of ARF in any form).

Although there was no regional variation within South Asia it was essentially a disease of the poor; overcrowding and under-nutrition rather than climate seemed to be the most important contributory factors. Over the course of time, the incidence of ARF and prevalence of RHD has dramatically declined perhaps attributable to improved living conditions or easy availability of treatment for sore throat and prophylaxis of ARF.

Currently the newer type of valvular heart diseases (degenerative or congenital) is gaining in relative importance.

With declining trends of RHD, expert physicians/cardiologists trained in this area are becoming rarer to find. Moreover, newer VHDs may be more complex which might necessitate developing a whole “system of care,” adequate laboratory criteria for diagnosis, appropriate treatment; drugs, surgery and interventional procedures (TAVR, mitral valve repair/replacement, tricuspid valve repair/replacement etc) focused on patient outcomes.

A new VHD clinic

These kinds of systems already exist for heart failure, “ heart failure clinics” or arrhythmia clinics or STEMI “hub and spoke” model. American College of Cardiology has recently published a “2019 Expert Consensus to Optimize Care for Patients With Heart Valve Disease.” While this document is meant for physicians practising in the US, it can be adapted for Indian circumstance. This new “VHD Clinic” may involve:

A concept of a graduated system, with an initial tier of recognition and consideration for referral, followed by matching the patient based on disease complexity with the appropriate centre of expertise and available resources. This could be a ‘hub and spoke” model which includes the primary care physician and general cardiologist, either of whom can refer patients to either a Level II Primary Valve Centre or a Level I Comprehensive Valve Centre, with potential additional referrals between the Valve Centres.

1. 1st Step: The first stakeholder in this system would be a primary care physician / general cardiologist / advanced practice provider who would recognise VHD and make the subsequent diagnosis.
2. 2nd Step: The first contact physician / care provider would then refer the patient to a ‘specialist’ cardiologist who would further refine the diagnosis, initiate the indicated medical therapy, and identify which patients can be followed for the time being without intervention versus those patients who require an intervention and therefore need to be referred.
3. 3rd step: It requires referral to centres designated as having VHD expertise; not only perform certain procedures, but also have multidisciplinary teams capable of assessing and managing patients according to evidence-based guidelines while emphasizing shared decision making. These centres can, in turn, be of two types:

• Primary (Level II) Valve Centers: which should at a minimum have the expertise and resources to perform standard aortic valve replacement procedures with or without CABG, and/or transfemoral transcatheter AVR (TAVR). They should also have consistent access to high-quality echocardiography and an echocardiographer with expertise in VHD. -
• Comprehensive (Level I) Valve Centers: which should have the resources and capabilities to evaluate and perform all even more complex interventional and surgical procedures, including the ability to perform a durable mitral valve repair in patients with primary mitral regurgitation as well as complex surgical procedures including complex aortic root procedures including valve-sparing root repair, and the ability to treat patients with complicated infective endocarditis and/or TAVR using femoral/non-transfemoral approaches, valve-in-valve TAVR, transcatheter mitral valve edge-to-edge repair, and percutaneous closure of paravalvular leaks.

In addition, the Comprehensive Centers should have advanced imaging modalities including 3D echocardiography and cardiac MRI and “Interventional Echocardiographers” - echocardiographers possessing a sophisticated knowledge about and trained in the evaluation of complex valvular conditions along with clinical expertise to guide management decisions and interventions.

All valve centres should:

• Have a formal multidisciplinary team composed of health-care personnel with expertise in managing patients with VHD
• Participate in national registries
• Be in fore-front to evaluate new technologies and improve the clinical management in these patients
• Provide ongoing continuing medical education to 1st contact physicians along with participation at local, national, and international conferences
• Participate in the training of other VHD related health-care providers
• Publicly report outcomes of both surgical and trans-catheter interventions

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The writer, Dr. Sundeep Mishra is a Professor of Cardiology.