In April, the Journal of the American College of Cardiology published the results of a two-year collaboration between the AATS, ACC, ASE, SCA and STE¹ to recommend a system of care (SOC) and appropriate benchmarks regarding the “availability, delivery, organization and quality of cardiovascular care” for valvular heart disease (VHD).

Brian R. Lindman, M.D., medical director of the Structural Heart and Valve Center at Vanderbilt University Medical Center, was a working group member and author on the document. Lindman calls it a response to the rapid pace of change and expansion in this field. The need for centers that specialize in valve disease is driven by the increasing complexity of care.

“Today, we have complex multimodal imaging tools, the ability to analyze more nuances in patient anatomy, a greater number and variety of devices, and more older adults with multiple comorbidities and impaired physical function. These make it very challenging to match the right patient with the right therapy at the right time,” Lindman said.

Reducing Treatment Variability

Currently, there is fairly marked heterogeneity in the treatment of and outcomes for patients with VHD across different facilities. Treatment for mitral regurgitation among patients with degenerative mitral valve disease supplies an apt illustration. Literature shows a survival advantage for these patients who undergo mitral valve repair instead of replacement. Yet, because mitral valve repair is a more complex, technically demanding procedure than replacement, candidates for repair may have their valve replaced instead, Lindman says.

While a number of factors contribute to a higher valve repair rate, the volume and experience of the surgeon and center certainly contribute. “This document reflects an effort to move us in a direction in which this variability decreases, thereby improving patient outcomes,” Lindman said.

Defining Centers of Excellence

Until now, “valve centers of excellence” have been referred to but never defined. The expert consensus document addresses this in describing two levels of advanced valve centers:

  • Level I: Comprehensive Valve Centers
  • Level II: Primary Valve Centers.

The two levels diverge along several lines, including complexity of pathology and procedures, imaging needs, and required procedural volumes. For example, while both Level I and Level II centers would perform the transcatheter aortic valve repair (TAVR) procedure, only Level I centers would offer an alternative to transfemoral access. Both Level I and Level II centers would offer mitral valve replacement, but more complex mitral repair would usually occur at Level I centers.

Lindman notes the list of procedures and where it is anticipated they would be performed (Level I vs. II) is not fixed; some Level II centers will perform more or fewer types of procedures than others. Quality and patient outcomes will be the most important barometer how appropriate it is for a given center to perform certain procedures.

Lifting All Boats

While not a mandate or blueprint for accreditation, the SOC consensus document supplies parameters accrediting bodies may use to develop programs for heart failure and other subspecialties.

Lindman said, “Optimizing outcomes for patients with VHD must be a multi-faceted endeavor requiring—at both levels of advanced valve centers—suitable equipment and physical infrastructure, appropriately trained and experienced personnel, a team approach to evaluation and treatment, ongoing education and training, and systematic ways to track outcomes and improve processes.”

“The goal is to lift all boats and to bring some accountability and standards.”

“In the end, the goal is not to be restrictive in terms of what individual centers can do. The goal is to lift all boats and to bring some accountability and standards toward the ultimate goal of improving outcomes for patients with VHD,” Lindman said.

While there are not yet official designations of Comprehensive (Level I) or Primary (Level II) Valve Centers, Vanderbilt would reflect what is described as a Comprehensive (Level 1) Valve Center.

About the Expert

Brian R. Lindman, M.D.

Brian R. Lindman, M.D., M.S.C.I., is an associate professor of cardiology and medical director of the Structural Heart and Valve Center at Vanderbilt University Medical Center. His research is centered on calcific aortic stenosis, including biomarker discovery, risk prediction and elucidating pathophysiology to identify adjunctive interventions to improve outcomes.

FOOTNOTES

American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiology, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.