Expert Consensus Proposes Tiered System for Valvular Heart Disease

Megan Brooks

April 23, 2019

Optimizing care for valvular heart disease (VHD) is best accomplished with a two-tiered system of care, akin to that for stroke and trauma, says a new consensus document jointly developed by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS).

"The increasing burden of VHD, coupled with the emergence of improved imaging techniques, better surgical outcomes, and transcatheter therapies, has stimulated discussions regarding optimal strategies for care delivery," according to the writing committee, cochaired by Rick Nishimura, MD, Mayo Clinic, Rochester, Minnesota, and Patrick O'Gara, MD, Harvard Medical School, Brigham and Women's Hospital, Boston.

"The focus of this document is not to ask whether there are too many, too few, or just the right number of self-designated advanced valve centers, but rather to initiate a discussion regarding whether a regionalized, tiered system of care for patients with VHD that accounts for the differences in valve center expertise, experience, and resources constitutes a more rational delivery model than one left to expand continuously without direction," they emphasize.

The 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease was published online April 19 in the Journal of the American College of Cardiology, as well as in Catheterization and Cardiovascular Interventions, the Journal of the American Society of Echocardiography, the Journal of Thoracic and Cardiovascular Surgery, and the Annals of Thoracic Surgery.

The proposal advocates two tiers of valve centers — comprehensive (level I) and primary (level II) valve centers — each with minimum procedural, institutional, and infrastructural requirements. The major distinction between centers resides chiefly in the broader spectrum of services and higher density of expert personnel available at a comprehensive level I center.

Proceduralists at both level I and level II valve centers should be able to perform transcatheter aortic valve replacement (TAVR) using a transfemoral approach and percutaneous balloon aortic valve dilation. Level I valve centers should also have the personnel and facilities to perform alternative-access (nontransfemoral) site TAVR, including transthoracic and extrathoracic approaches.

"The intent is not to limit the number of centers per se, but rather to set performance and quality goals for a valve center to meet benchmarks to be considered either comprehensive or primary in a manner that would be more objective than simple self-designation," the committee writes.

"The guiding principle in such a model would be to optimize the care of the individual patient by ensuring access to the right care in the right place at the right time, while promoting shared decision making and respecting individual values and preferences," they note.

The system would also promote the efficient use of resources, facilitate communication and continuity of care, and emphasize the need for transparency in the reporting of and accountability for outcomes relative to national benchmark, the committee says.

"There is a great deal of detailed work ahead to realize the goals of this proposal to the satisfaction of patients and the many other stakeholders involved," they add.

This research had no commercial funding. Full disclosures for the writing committee are listed with the original article.

J Am Coll Cardiol. Published online April 19, 2019. Full text

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