Introduction The long-term management of patients following valve replacement is challenging. The fields of percutaneous and surgical valves are expanding rapidly, leading to increased service demands. Most patients in our institution are managed within a dedicated cardiac physiologist’ run valve clinic. Initially, follow-up centred around ESC 2012 guidelines on the management of valve disease, which recommended a baseline clinical and echocardiographic assessment after surgery and lifelong annual clinical follow-up. In addition, they recommended annual echocardiogram 5 years for bioprosthetic valves with no specific guidance for mechanical valves. Locally, all patients enrolled into the valve clinic received annual clinical and echocardiographic assessment. In 2019, the BHVS/ BSE published more comprehensive guidance on long-term follow-up of these patients. The Covid-19 pandemic placed pressure on the NHS to reduce outpatient appointments. Prior to service alteration, we conducted an audit to expand our understanding of outcomes in these patients.
Methods We retrospectively analysed the data of all patients enrolled in our valve service. We assessed demographics, date and indication for surgery, prosthesis type and position, baseline assessment, frequency of follow-up and significant valve-related complications. Complications constituted: any degree of paravalvular regurgitation, ≥moderate transvalvular regurgitation, raised transvalvular gradients, valve thrombosis, infective endocarditis, new LV dysfunction, need for re-intervention, cardiac-related hospital admission and valve-related death.
Results We identified 294 patients who underwent valve replacement since clinic establishment in 2010. Patient demographics are shown in table 1. Only 37% of patients had baseline echocardiogram following surgery. Once enrolled into the clinic, 82.7% had yearly clinical and echocardiographic assessment. Table 2 demonstrates the echocardiographic and clinical complications we identified. During follow up 20.7% developed regurgitation, 9.5% developed abnormal gradients and one required re-intervention for re-stenosis. One patient had valve thrombosis and was managed medically. Additionally, 9.2% were diagnosed with new LV dysfunction; four of these required admission with decompensated heart failure and one died. 3.4% developed infective endocarditis; three required re-do surgery and four died. Figure 1 provides a schematic of valve-related complications and outcomes. Importantly, all patients who required admission, re-do surgery or that died, presented acutely with symptoms; the complications were not picked-up by the valve clinic.
Conclusions Contrast to our expectations, we identified only a small number of valve-related complications. With pressures rising to reduce outpatient footprint, we are now in the process of safely adjusting our practice in line with the BHVS/ BSE recommendations, supported by the evidence generated by our audit. We strongly encourage departments review their current services and implement evidence-based guidelines in the long-term management of patients with valve replacements.
Conflict of Interest None
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