Prosthetic Valves - Mark Dayer



Cardiology Follow-Up – Dr Mark Dayer

• Routine out patient follow-up should be regarded as the exception rather than the norm, although it is not inappropriate in all cases.

• Any patient who needs to be followed-up should be discussed with the consultant responsible for their care.

• Follow up of patients awaiting test results should only occur if a result is expected which will require complex discussion with the patient.

• Discharging patients will free up time in the service allowing us to see patients who have become unstable in a more timely fashion.

• When following up valve patients by echo rather than in person routinely, there are a number of exceptions:

o Patients with severe valve disease who may require surgery should be seen in person.

o There is sometimes a discrepancy between the clinical findings and the echo findings and these patients may be best seen in person.

o Where the echocardiogram is unclear patients may be best seen in person.

Ward Patients

• Ward patients will only receive an out-patient appointment if it is specifically requested by a cardiology consultant or there remains an outstanding issue which needs a cardiology decision.

• Patients should be advised that they will receive the next available or a routine appointment.

• If patients need to be seen within a short timeframe then a specific request to the booking staff from the consultant is required.

Outpatients

• Outpatients should not routinely be followed-up. For example stable angina, treated palpitations and treated hypertension are not conditions that require routine follow up.

Congenital Heart Disease

• A specialist area and beyond the scope of these guidelines. At Taunton they should all be followed-up in the joint clinics by David MacIver and Graham Stuart.

Post PCI

• Post PCI patients are seen in nurse-led clinics and do not require follow-up unless there is a particular reason – for example to determine if a second lesion requires intervention.

Post CABG

• These patients will be seen by the surgeons post-operatively and then receive cardiac rehabilitation. They should not be seen routinely in cardiology outpatients unless there is an outstanding medical issue.

Prosthetic valves

After some discussion the consensus opinion is as follows:

• All patients who have had a valve replacement/repair should be seen once in clinic and a baseline echo should be performed. Most patients should then be discharged.

• It is appropriate to follow-up, usually yearly:

o Patients who have had a mitral valve replacement.

o Patients who have had more than one valve replaced.

o Patients who have a residual valve lesion/other cardiological condition that may require intervention in time, for example a young patient with severe heart failure after a mitral valve repair.

o Patients in whom a complication, such as patient-prosthesis mismatch or a para-valvular leak is identified.

• It should be emphasised in the discharge letter that the recurrence of symptoms, for example breathlessness, should prompt an urgent re-referral.

• Tissue valves should have an echo every 5 years.

Most arrhythmias

• Should not require follow-up.

Post DCCV

• Patients undergoing procedures such as cardioversion should have a management plan in the notes which can be followed. They should be followed-up once by the arrhythmia/cardioversion nurses.

Devices

• Most simple pacemakers should not require routine follow-up and can be followed-up in pacing clinic.

• It is reasonable to see ICDs/CRTs once post-op. For ICDs that can be at the time of the DFT test (these are done 4-6 weeks after implant at Taunton & Somerset NHS Trust) unless it is within a few days.

Post Ablation

• Most people who have had an ablation will be seen in the centre where the ablation was done post-operatively and do not need follow-up unless there is a specific clinical reason.

Heart failure

• Most patients with heart failure should be followed up in the community.

• The only indications for follow up are:

o If transplantation is being considered if symptoms worsen or fail to improve.

o If a device may be indicated.

o If renal replacement therapy may be required.

o If there is clinical instability which has proven difficult to control in primary care and admission may be avoided.

o To discuss end-of-life issues.

• Uptitration of medication should normally be undertaken by the GP or community heart failure specialist nurses.

Hypertension

• Should not require routine follow-up unless there are significant issues with BP control.

Pulmonary Hypertension

• Should be routinely followed by the respiratory physicians, unless secondary to valve disease under follow-up. Most patients with significant pulmonary hypertension should be referred onto the regional service.

Native Valve Disease

• The most common reason for follow-up is native valve disease.

• The availability of percutaneous valve techniques means that patients previously ineligible for intervention may now be suitable for intervention.

• See the latest ACC/AHA guidelines.

Tricuspid and pulmonary valve disease

• There are very few patients with significant tricuspid and pulmonary valve disease requiring follow-up and most of these will have underlying congenital heart disease. They should be followed-up by David MacIver in the congenital heart disease clinic if appropriate.

Mitral stenosis

• Echocardiography is reasonable in the re-evaluation of asymptomatic patients with MS and stable clinical findings to assess pulmonary artery pressure (for those with severe MS, every year; moderate MS, every 1 to 2 years; and mild MS, every 3 to 5 years).

Mitral regurgitation

• Mild MR with leaflet prolapse (or suspicion of): 3-5 years.

• Moderate MR: 1 year.

• Severe MR: 6 months.

Aortic stenosis (asymptomatic)

• Mild AS: 3-5 years.

• Moderate AS: 1-2 years.

• Severe AS: 1 year.

• Patients with bicuspid aortic valves and dilatation of the aortic root or ascending aorta (diameter greater than 4.0cm – NB. need to correct for body surface area) should undergo serial evaluation of aortic root/ascending aorta size and morphology by echocardiography, cardiac magnetic resonance, or computed tomography on a yearly basis.

Aortic regurgitation (asymptomatic, normal LV function)

• After an initial diagnosis of moderate to severe AR it is appropriate to review the patient in 2-3 months to ensure a rapidly progressive process is not underway.

• Asymptomatic patients with mild AR, little or no LV dilatation, and normal LV systolic function can be seen on a yearly basis, with instructions to alert the physician if symptoms develop in the interim. Yearly echocardiography is not necessary unless there is clinical evidence that regurgitation has worsened. Routine echocardiography can be performed every 2 to 3 years in such patients.

• Asymptomatic patients with normal systolic function but severe AR and significant LV dilatation (end-diastolic dimension greater than 60 mm), if not referred for surgery, require more frequent and careful re-evaluation, with a history and physical examination every 6 months and echocardiography every 6 to 12 months, depending on the severity of dilatation and stability of measurements. If patients are stable, echocardiographic measurements are not required more frequently than every 12 months.

• In patients with more advanced LV dilatation (end-diastolic dimension greater than 70 mm or endsystolic dimension greater than 50 mm), if not referred for surgery, for whom the risk of developing symptoms or LV dysfunction ranges between 10% and 20% per year, it is reasonable to perform serial echocardiograms as frequently as every 4 to 6 months.

• Patients with echocardiographic evidence of progressive ventricular dilatation or declining systolic function have a greater likelihood of developing symptoms or LV dysfunction and should have more frequent follow-up examinations (every 6 months) than those with stable LV function.

Thoracic Aortic Aneurysms/Dilated Aortic Roots/Post Aortic Root repair/replacement

• This is a complex situation and precise guidelines on follow-up are difficult.

• As a general rule, patients with a dilated aortic root require yearly follow-up, but more frequent follow-up may be required.

• It is generally appropriate to follow patients on a yearly basis after aortic repair, unless there is concomitant follow-up at the operating centre, in which case it is not required here.

Heart transplantation

• Yearly follow-up.

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