The Heart Valve Centre

  • John B. ChambersEmail author
  • Patrizio Lancellotti


Heart valve centers of excellence include a specialist valve clinic and multidisciplinary teams delivering interventions. The valve clinic assesses new outpatients and monitors those with moderate and severe valve disease to determine the optimum timing of surgery. It also supervises inpatient care for valve disease including infective endocarditis. The minimum interventions offered are: replacement of valves in all 4 positions; mitral valve repair; tricuspid annuloplasty and repair; ancillary procedures, left atrial appendage closure, AF ablation; percutaneous balloon mitral valvotomy; TAVI; percutaneous repair of paraprosthetic regurgitation; aortic replacement. The core of the multidisciplinary teams is a cardiologist specialising in valve disease, an echocardiographer, an interventional cardiologist and a surgeon. There must be expert imaging including CMR and CT and a variety of cardiac and non-cardiac associated specialists including electrophysiologists, intensivists, spinal specialists and geneticists. This chapter discusses consensus views on standards for the components of the center of excellence including individual surgeon and center volumes. Good results are usually associated with high individual and center volumes, but this relationship is complex. Results of surgery should be published by center and should include rates of residual regurgitation rates for mitral repairs and reoperation rates matched to the preoperative pathology and risk. The center should be involved with methods of improving detection of valve disease in the community and national programmes of training and audit.


Heart valve disease Multidisciplinary teams Heart valve center of excellence Heart valve clinic 


  1. 1.
    Lancellotti P, Rosenhek R, Pibarot P, Iung B, Otto CM, Tornos P, et al. Heart valve clinics: organisation, structure and experiences. Eur Heart J. 2013;34:1597–606.CrossRefGoogle Scholar
  2. 2.
    Chambers J, Sandoe J, Ray S, Prendergast B, Taggart D, Westaby S, et al. The infective endocarditis team: recommendations from an international working group. Heart. 2014;100:524–7.CrossRefGoogle Scholar
  3. 3.
    Arden C, Chambers J, Ray S, Prendergast B, Taggart D, Westaby S, Grothier L, Wilson J, Campbell B, Sandoe J, Gohlke-Bärwolf C, Mestres C, Rosenhek R, Pibarot P, Otto C. Can we improve the detection of heart valve disease? Heart. 2014;100:271–3.CrossRefGoogle Scholar
  4. 4.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. AHA/ACC Guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2014. Scholar
  5. 5.
    Chambers J, Ray S, Prendergast B, Graham T, Campbell B, Greenhalgh D, Petrou M, Tinkler J, Gohlke-Bärwolf C, Mestres C, Rosenhek R, Pibarot P, Otto C, Sundt T. Standards for heart valve surgery in a ‘Heart Valve Centre of Excellence’. Open Heart. 2015b;2(1):e000216.CrossRefGoogle Scholar
  6. 6.
    Chambers J, Prendergast B, Iung B, Rosenhe R, Zamoran JL, Piérard LA, Modine T, Falk V, Kappetein AP, Pibarot P, Sundt T, Baumgartner H, Bax JJ, Lancellotti P. Standards defining a “Heart Valve Centre”: ESC Working Group on Valvular Heart Disease and European Association for Cardiothoracic Surgery Viewpoint. Euro Heart J. 2017;38:2177–83; and Eur J Cardiothorac Surg 2017;52:418–24CrossRefGoogle Scholar
  7. 7.
    Fink JC, Schmid CH, Selker HP. A decision aid for referring patients with systolic murmurs for echocardiography. J Gen Int Med. 1994;9:479–84.CrossRefGoogle Scholar
  8. 8.
    Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997;278:717–22.CrossRefGoogle Scholar
  9. 9.
    Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Barwolf C, Levang OW, Tornos P, Vanoverschelde J-L, Vermeer F, Boersma E, Ravaud P, Vahanian A. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on valvular heart disease. Eur Heart J. 2003;24:1231–43.CrossRefGoogle Scholar
  10. 10.
    Taggu W, Topham A, Hart L, Carr-White G, Sulke N, Patel NR, Lloyd G. A cardiac sonographer led follow up clinic for heart valve disease. Int J Cardiol. 2009;132:240–3.CrossRefGoogle Scholar
  11. 11.
    Iung B. Management of the elderly patient with aortic stenosis. Heart. 2008;94:519–24.CrossRefGoogle Scholar
  12. 12.
    Savage EB, Ferguson TB, DeSesa VJ. Use of mitral valve repair: analysis of contemporary United States experience reported by the society of thoracic surgeons national cardiac database. Ann Thorac Surg. 2003;75:820–5.CrossRefGoogle Scholar
  13. 13.
    Nihoyannopoulos P, Fox K, Fraser A, Pinto F. EAE laboratory standards and accreditation. Eur J Echo. 2007;8:80–7.CrossRefGoogle Scholar
  14. 14.
    Picard MH, Adams D, Bierig SM, et al. American Society of Echocardiography recommendations for quality echocardiography laboratory operations. J Am Soc Echo. 2011;24(1):1–10. Scholar
  15. 15.
    Van Dyck MJ, Watremez C, Boodwhani M, Vanoverschelde J-L, El Khoury G. Transesophageal echocardiographic evaluation during aortic valve repair surgery. Anesth Analg. 2010;111:59–70.CrossRefGoogle Scholar
  16. 16.
    McCarthy PM. When is your surgeon good enough? When do you need a ‘referent surgeon’? Curr Cardiol Rep. 2009;11:107–13.CrossRefGoogle Scholar
  17. 17.
    Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety. From concept to measurement. Ann Surg. 2004;239:475–82.CrossRefGoogle Scholar
  18. 18.
    Bridgewater B, Hooper T, Munsch C, et al. Mitral repair best practice: proposed standards. Heart. 2006;92:939–44.CrossRefGoogle Scholar
  19. 19.
    Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008;117:963–74.CrossRefGoogle Scholar
  20. 20.
    David TE, Ivanov J, Armstrong S. Late outcomes of mitral valve repair for floppy valves: implications for asymptomatic patients. J Thorac Cardiovasc Surg. 2003;125:1143–52.CrossRefGoogle Scholar
  21. 21.
    Braunberger E, Deloche A, Berrebi F, Abdallah F, Celestin JA, Meimoun P, Chatellier G, Chavaud S, Fabiani JN, Carpentier A. Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques with non rheumatic mitral valve insufficiency. Circulation. 2001;104(12 Suppl 1):I8–11.CrossRefGoogle Scholar
  22. 22.
    Tomasso CL, Bolman RM, Feldman T, et al. Multisociety (AATS, ACCF, SCAI, and STS) expert consensus statement: operator and institutional requirements for transcatheter valve repair and replacement, part 1: transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59:2028–42.CrossRefGoogle Scholar
  23. 23.
    Tommaso CL, Fullerton DA, Feldman T, et al. SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement. Part II mitral valve. J Am Coll Cardiol. 2014;64:1515–26.CrossRefGoogle Scholar
  24. 24.
    Ionescu A, McKenzie C, Chambers J. Are valve clinics a sound investment for the health service? A cost-effectiveness model and an automated tool for cost estimation. Open Heart. 2015;2:e000275. Scholar
  25. 25.
    Parkin D, Chambers J. Routine follow-up for patients with prosthetic valves: the value of a nurse-led valve clinic. Br J Cardiol. 2012;19:204–6.CrossRefGoogle Scholar
  26. 26.
    Parkin D, Chambers J. What is the value of a nurse-led clinic for patients with replacement heart valves? Br J Cardiac Nurs. 2015;10:145–9.CrossRefGoogle Scholar
  27. 27.
    Chambers JB, Lloyd G, Rimington HM, Parkin D, Hates AM, Baldrock-Apps G, Topham A. Multidisciplinary valve clinics with devolved surveillance: a 2 year audit. Br J Cardiol. 2011;18:231–2.CrossRefGoogle Scholar
  28. 28.
    Bhattacharyya S, Pavitt C, Lloyd G, Chambers JB. Provision, organisation and models of heart valve clinics within the United Kingdom. Q J Med. 2015;108:113–7. First published online: 6 Aug 2014.CrossRefGoogle Scholar
  29. 29.
    Bruun NE, Habib G, Thuny F, Sogaard P. Cardiac imaging in infectious endocarditis. Eur Heart J. 2014;35:624–32.CrossRefGoogle Scholar
  30. 30.
    Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Learning minimally-invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high volume center. Circulation. 2013;128:483–91.CrossRefGoogle Scholar
  31. 31.
    Kilic A, Shah AS, Conte JV, Baumgartner WA, Yuh DD. Operative outcomes in mitral valve surgery: combined effects of surgeon and hospital volume in a population-based analysis. J Thorac Cardiovasc Surg. 2013;146:638–46.CrossRefGoogle Scholar
  32. 32.
    Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology foundation/American Heart Association task force on practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574–651.PubMedGoogle Scholar
  33. 33.
    Karthikesingam A, Hinchcliffe RJ, Loftus IM, Thompson MM, Holt PJ. Volume-outcome relationships in vascular surgery: the current status. J Endovasc Ther. 2010;17:356–65.CrossRefGoogle Scholar
  34. 34.
    Bolling SF, Li S, O’Brien SM, Brennan JM, Prager RL, Gammie JS. Predictors of mitral valve repair: clinical and surgeon factors. Ann Thorac Surg. 2010;90:1904–11.CrossRefGoogle Scholar
  35. 35.
    Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation. 2007;115:881–7.CrossRefGoogle Scholar
  36. 36.
    Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128–37.CrossRefGoogle Scholar
  37. 37.
    Vassileva CM, Boley T, Markwell S, Hazelrigg S. Impact of hospital annual mitral procedural volume on mitral valve repair rates and mortality. J Heart Valve Dis. 2012;21:41–7.PubMedGoogle Scholar
  38. 38.
    Rahimtoola SH. Choice of prosthetic heart valve in adults. J Am Coll Cardiol. 2010;55:2413–26.CrossRefGoogle Scholar
  39. 39.
    Unger P, Dedobbeleer C, van Camp G, Plein D, Cosyns B, Lancellotti P. Mitral regurgitation in patients with aortic stenosis undergoing valve replacement. Heart. 2010;96:9–14.CrossRefGoogle Scholar
  40. 40.
    Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.CrossRefGoogle Scholar
  41. 41.
    Aicher D, Fries R, Rodionycheva S, Schmidt K, Langer F, Schaefers HJ. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg. 2010;37:127–32.CrossRefGoogle Scholar
  42. 42.
    Langer F, Aicher D, Kissinger A, Wendler O, Lausberg H, Fries R, Schaefers H-J. Aortic valve repair using a differentiated surgical strategy. Circulation. 2004;110(Suppl II):II-67–73.Google Scholar
  43. 43.
    le Polain de Waroux JB, Pouleur AC, Robert A, Pasquet A, Gerber BL, Noirhomme P, El Khoury G, Vanoverschelde JL. Mechanisms of recurrent aortic regurgitation after aortic valve repair. J Am Coll Cardiol Cardiovasc Imaging. 2009;2:931–9.CrossRefGoogle Scholar
  44. 44.
    Botelho-Nevers E, Thuny F, Casalta JP, et al. Dramatic reduction in infective endocarditis-related mortality with a management-based approach. Arch Intern Med. 2009;169:1290–8.CrossRefGoogle Scholar
  45. 45.
    Tornos P, Iung B, Permanyer-Miralda G, Baron G, Delahaye F, Gohlke-Bärwolf C, Butchart EG, Ravaud P, Vahanian A. Infective endocarditis in Europe: lessons from the Euro heart survey. Heart. 2005;91(5):571.CrossRefGoogle Scholar
  46. 46.
    Ruttmann E, Hangler HB, Kilo J, Hṏfer D, Műller LC, Hintringer F, Műller S, Laufer G, Antretter H. Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis. Pacing Clin Electrophysiol. 2006;29:231–6.CrossRefGoogle Scholar
  47. 47.
    Thuny F, Beurtheret S, Mancini J, et al. The timing of surgery influences mortality and morbidity in adults with severe complicated endocarditis: a propensity analysis. Eur Heart J. 2011;32:2027–33.CrossRefGoogle Scholar
  48. 48.
    Iung B, Rousseau-Paziaud J, Cormier B, Garbarz E, Fondard O, Brochet E, Acar C, Couëtil J-P, Hvass U, Vahanian A. Contemporary results of mitral valve repair for infective endocarditis. J Am Coll Cardiol. 2004;43:386–92.CrossRefGoogle Scholar
  49. 49.
    d’Arcy JL, Coffey S, Loudon M, Kennedy A, Pearson-Stuttard J, Birks J, Frangou E, Farmer AJ, Mant D, Wilson J, Myerson SG, Prendergast BD. Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: The OxVALVE Population Cohort Study. Eur Heart J. 2016;37(47):3515–22. Scholar
  50. 50.
    Roldan CA, Shively BK, Crawford MH. Value of cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects. Am J Cardiol. 1996;77:1327–31.CrossRefGoogle Scholar
  51. 51.
    Marijon E, Ou P, Celermajer S, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. 2007;357:470–6.CrossRefGoogle Scholar
  52. 52.
    McDonald, Daly, Jelinek, et al. Opening Pandora’s box: the unpredictability of reassurance by a normal test result. Br Med J. 1996;313:329–32.CrossRefGoogle Scholar
  53. 53.
    Stoate HG. Can health screening damage your health? JR Coll Gen Pract. 1989;39:193–5.Google Scholar
  54. 54.
    Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011. Appropriate use criteria for echocardiography. JACC. 2011;57:1126–66.CrossRefGoogle Scholar
  55. 55.
    Chambers JB, Kabir S, Cajeat E. The detection of heart disease by open access echocardiography: a retrospective analysis. Br J Gen Pract. 2014;64:86–7.CrossRefGoogle Scholar
  56. 56.
    McBride KL, Garg V. Heredity of bicuspid aortic valve: is family screening indicated? Heart. 2011;97:1193–5.CrossRefGoogle Scholar
  57. 57.
    Warnes CA, Williams RG, Bashore TM, et al. 2008 guidelines for the management of adults with congenital heart disease. JACC. 2008;52:e1–e121.CrossRefGoogle Scholar
  58. 58.
    Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. 2005;5:685–94.CrossRefGoogle Scholar
  59. 59.
    Eveborn GW, Schirmer H, Heggelund G, et al. The evolving epidemiology of valvular aortic stenosis. The Tromso Study. Heart. 2012;99(6):396–400. Scholar
  60. 60.
    Lindroos M, Kupari M, Heikkila J, et al. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21:1220–5.CrossRefGoogle Scholar
  61. 61.
    Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease. JACC. 1997;29:630–4.CrossRefGoogle Scholar
  62. 62.
    Grant SW, Devbhandari MP, Grayson AD, et al. What is the impact of providing a Transcatheter Aortic Valve Implantation (TAVI) service on conventional aortic valve surgical activity, patient risk factors and outcomes in the first two years? Heart. 2012;96:1633–7.CrossRefGoogle Scholar
  63. 63.
    Grant SW, Hickey GL, Cosgriff R, Cooper G, Deanfield J, Roxburgh J, Bridgewater B. Creating transparency in UK adult cardiac surgery data. Heart. 2013;99:1067–8.CrossRefGoogle Scholar
  64. 64.
    Wijns W, Kolh PH. Experience with revascularization procedures does matter: low volume means worse outcome. Eur Heart J. 2010;31(16):1954–7. Scholar
  65. 65.
    Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006;113:2238–44.CrossRefGoogle Scholar
  66. 66.
    Zilbersak R, Gabriel H, Maurer G, Rosenhek R. Optimized timing of surgery in aortic stenosis: impact of a valve clinic programGoogle Scholar
  67. 67.
    Gurzun MM, Ionescu A. Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? Eur Heart J Cardiovasc Imaging. 2014;15:450–5.CrossRefGoogle Scholar
  68. 68.
    Zaidi A, Ionescu A, Sharma R, et al. Echocardiographic surveillance of aortic valve stenosis: towards a standardized approach. J Heart Valve Dis. 2012;21:707–13.PubMedGoogle Scholar
  69. 69.
    Turpie D, Maycock M, Crawford C, et al. Establishing an aortic surveillance clinic. Br J Cardiol. 2010;17(6):286–9.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiothoracic Centre, Guy’s and St Thomas’ HospitalsLondonUK
  2. 2.Department of CardiologyUniversity of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, CHU Sart TilmanLiègeBelgium
  3. 3.GVM Care and Research, E.S. Health Science FoundationLugoItaly

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