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British Heart Valve Society Newsletter - March 2018

Welcome! 





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Message from Mr Norman Briffa, President

 

Dear BHVS Member,  

 

Welcome to this new edition of the Newsletter for BHVS members. As usual we have a whole range of exciting items of interest to all those who have an interest in Heart valve disease. As a society we continue to strive to achieve the aims stated in our logo i.e. to educate and to ensure best practice in heart valve disease. We are hoping to attract funding to upgrade the website to make it fit for purpose to achieve these aims. 

Dr Laura Hobson who is our current Communication secretary and who has achieved so much in a relatively short period will be stepping down shortly and the society will be looking for a replacement Communication Secretary.  The Job specification for the post should be coming your way soon. 

 

Mr Norman Briffa

 
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Guidelines in focus: ESC/EACTS Guidelines for the management of valvular heart disease

These recently published guidelines supersede the 2012 version and take into account the vast progression seen in the development of transcatheter therapies since the last iteration and also recognise the increasing role of multimodality imaging in the assessment of valve disease. 

 

What's new in the guidelines?

i) General care

The introduction of the concept of the 'Heart Valve Team' and 'Heart Valve Centres' offering a wide range of diagnostic, surgical and transcatheter interventions. 

Novel oral anticoagulants (NOACs) are now recognised as suitable alternatives of thromboembolic prevention in all patients with valve disease with the exception of moderate to severe mitral stenosis and mechanical valve replacements. 

CT coronary angiography should be considered for the assessment of coronary anatomy in low risk patients undergoing valve surgery (i.e. pre-menopausal women, men < 40 years among others).

The use of aspirin in addition to warfarin in those with a prosthetic heart valve or repair and concomitant coronary artery disease (CAD) has been downgraded from a IIA to IIB recommendation. 

ii) Aortic stenosis

An increasing role for multimodality imaging in the assessment of complex patients with aortic stenosis (AS). Specifically, the recommendation that CT calcium scoring may be helpful in the context of discrepant echocardiographic data (e.g. MPG < 40 mmHg and AVA < 1 cm2).

Elevated BNP levels (>3x upper limit of normal) without alternative cause upgraded from IIB to IIA recommendation as an indication for surgery in asymptomatic AS. 

Severe pulmonary hypertension at rest (>60 mmHg) is now a IIA recommendation for SAVR in asymptomatic severe AS. 

Intervention in low flow, low gradient severe AS with reduced LVEF and no contractile reserve is upgraded from a class IIB to IIA recommendation if CT calcium scoring confirms severe AS. 

TAVI receives much greater emphasis, with guidance on potential scenarios where TAVI may be preferred over SAVR. An increasing recognition that TAVI may be appropriate in intermediate surgical risk groups, especially in patients over 75 years where a transfemoral approach is feasible, accepting that data are still limited regarding bicuspid valves and the longevity of TAVI bioprostheses. 

iii) Aortic regurgitation 

Aortic valve repair is recommended over replacement in young patients with tricuspid valves and aortic root dilatation if local surgical expertise is available. 

Baseline cross sectional imaging (CMR or CT) is advised for all those with a dilated aortic root (>40 mm). This differs from the ESC guidelines on aortic disease which only suggest cross-sectional imaging in the case of aortic dilatation > 45 mm or poor TTE views. 

iv) Mitral regurgitation 

An aggressive, early surgical approach is upgraded from a IIB to IIA recommendation in patients with asymptomatic severe primary MR where there is preserved LVEF, LVEDD 40-44mm and left atrial dilatation if the surgical risk is low and there is a high likelihood of durable repair. 

Mitral valve edge to edge repair enters into the guidelines for patients with symptomatic primary and secondary severe MR at prohibitive/high surgical risk as a IIB recommendation. 

v) Prosthetic valves 

Thirty day post-implant TTE is recommended in all patients undergoing biological SAVR or TAVI, with annual echocardiographic and clinical follow-up thereafter. New details guidance on anti-platelet therapy in patients on anticoagulation of valve disease undergoing PCI is provided. 

 

What's remained the same?

Transthoracic echocardiography remains the primary assessment modality for patients with valvular heart disease  with other modalities (TOE, CT, stress echocardiography, CMR, fluoroscopy, biomarkers etc.) recommended where diagnostic uncertainty remains. 

 

What's been removed?

Increase in mean aortic valve gradient and excessive LV hypertrophy are no longer indications for surgery in patients with severe asymptomatic AS. Additionally, the recommendation for surgical intervention on the mitral valve in secondary (functional) MR at the time of CABG has been removed. 

EuroSCORE is no longer recommended as a risk scoring system due to its tendency to overestimate surgical risk and poor discriminatory power.  Exercise induced pulmonary hypertension is no longer recommended as a trigger for surgical referral in patients with asymptomatic severe primary mitral regurgitation.  Invasive measure of AV gradient in severe AS is no longer recommended. 

 

The full 53 (!) page document can be downloaded via the following link. Pocket guidelines are available to download from Apple and Android stores. 

 
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Interview with Dr Marc Dweck, Senior Lecturer & Consultant Cardiologist, Edinburgh Heart Centre

 

Q. Could you run us through your career to date? How did you become interested in valve disease research?

 

I was a medical student in Edinburgh and have done most of my training here. I did SHO rotations in London and imaging fellowships in New York and Los Angeles but something keeps drawing me back to Scotland's capital.  My academic career started with a PhD in Edinburgh under the supervision of Prof David Newby, Dr Nick Boon and Dr James Rudd (Cambridge).

We secured a grant from the British Heart Foundation to investigate the pathophysiology of aortic stenosis using positron emission tomography (PET). In particular we wanted a tracer to inform about calcification and tried the well-established PET bone tracer 18F-fluoride. We got lucky. 18F-fluoride worked beautifully as a marker of vascular calcification activity, confirming that calcification is the predominant process driving aortic stenosis progression and opening up a whole new area of cardiovascular research that we are actively exploring today. Indeed it laid the foundations for the on going SALTIRE 2 randomised controlled trial testing whether drugs targeting calcium metabolism can slow aortic stenosis progression (ClinicalTrials.gov NCT02132026).

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18F-Fluoride PET images of the aortic valve in patients with aortic stenosis. Red/yellow areas demonstrate areas of calcification activity in the aortic valve. (Pawade et al Circ Imaging 2016)

We soon realised that in order to truly understand aortic stenosis you need to consider not only how the valve narrows but also how the left ventricle copes with this narrowing. We therefore wrote a further BHF grant to perform cardiovascular magnetic resonance (CMR) in our aortic stenosis patients to investigate the hypertrophic response of the left ventricle and in particular what drives its decompensation. This project has been a great collaborative endeavour involving multiple expert groups around the United Kingdom and taking advantage of the rich concentration of imaging expertise that we have in this country. Ultimately we have demonstrated that CMR can detect myocardial scarring in patients with aortic stenosis as a sign that their heart is starting to fail. We think detection of such scarring could prove really helpful in deciding upon when best to replace the valve and have designed the EVOLVED randomised controlled trial to test this hypothesis.

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Mid-wall fibrosis (red arrows) detected on CMR imaging in patients with aortic stenosis.

Q. Could you run us through the design of your new study - EVOLVED? 

EVOLVED is a randomised controlled trial testing whether early surgery or TAVI in patients with asymptomatic severe aortic stenosis and evidence of left ventricular decompensation (scarring in their ventricle) is superior to the standard approach of waiting for symptom development.

 

It is a multicentre study with over 20 centres in the UK participating and will be the first RCT to evaluate the optimum timing of heart valve surgery (Clinicaltrials.gov NCT03094143). It is funded as part of the Sir Jules Thorn Award for Biomedical Science, which I was awarded in 2015. We believe that operating earlier in patients who are starting to develop irreversible scarring of their heart muscle will improve their long-term prognosis by stopping the left ventricle from decompensating further. Whilst we will use CMR to identify this scarring, we were keen to ensure this strategy remains cost effective. We are therefore first screening patients with an ECG and /or blood test (high sensitivity troponin I). Only those patients with evidence of LV decompensation on these routine tests will proceed to CMR, thereby limiting the number of CMR scans performed and maximising cost-effectiveness. The trial has recently started recruitment and our goal is to recruit 1000 patients across the UK for CMR imaging. Follow up will be for 2 to 4 years and the primary end point is all cause mortality + unplanned hospital admission related to aortic stenosis.

 

We would strongly welcome new sites not already participating in the trial.

 

Q. How do you see the treatment of heart disease evolving over the next 10 years?

The treatment of heart valve disease remained largely stagnant for 30 or 40 years. Then along came TAVI and suddenly everyone became interested in heart valve disease. Indeed, this shift looks set to revolutionise the treatment of these conditions. I think the indications for TAVI will continue to expand although we really do need to understand whether these valves last as long as surgical one before we start putting them in to younger fitter patients. However, with industry support the technology will continue to improve and newer percutaneous techniques for other valve conditions will also emerge. I would also like to see this advance coupled with more sophisticated approaches to the timing of valve intervention as is being investigated in EVOLVED. However ultimately what we really need are medical therapies aimed at slowing disease progression so that valve intervention in avoided altogether. As our understanding of the pathophysiological mechanisms underlying valve disease improves I believe these medical interventions will be developed. As such I think the next decade or two will see the treatment of heart valve disease evolve from surgical to percutaneous intervention and then finally to medical therapy: a highly exciting future that I am looking forward to being involved with.


Contacts

EVoLVeD Trial Manager: evolved.trial@ed.ac.uk

Dr Marc Dweck: @MarcDweck marcdweck@ed.ac.uk 

 

Research News

As many of you are aware the EASY AS study was submitted to the BHF in March 2017.  This is was a joint BHVS/SCTS initiative to test the hypothesis that early valve replacement before symptoms develop leads to better outcomes in patients with severe AS than waiting for symptoms to develop. The study proposed to recruit 1134 patients in the UK and Australia and although the BHF indicated they would be prepared to fund the study the simultaneous submission to the Australian MHRC failed.  We are now preparing a repeat submission to the BHF in Feb 2014 and are looking for additional sites in the UK. We are hoping to have approximately 35 surgical centres with their referring secondary care hospitals included.  The study will overlap with the EVOLVED AS trial and are not mutually exclusive- it is likely that recruitment for EVOLVED will be near completion by the time EASY AS starts.

 

If you are interested in participating in this landmark study (all investigators will be acknowledged in the paper as contributors) please email Professor Gerry McCann ( gpm12@le.ac.uk).

Interesting Reads

The European Heart Journal has offered free access to the "Standards defining a Heart Valve Centre" consensus paper, first authored by John Chambers. The free access was offered at the request of the ESC Council on Heart Valve Disease. 

Upcoming Events

 
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US Heart Valve Society: Annual Scientific Meeting

New York, USA

 

April 12th - 14th 

 

Full price: $800

Allied health professionals: $400

Trainees: $335

 

 
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British Cardiovascular Society: Annual Conference

Manchester, UK 

 

June 4th - 6th


Registration opens soon 

 

 

 

 
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