Valve disease is increasingly common as our population ages. Judging the timing of surgery is hard in all types of valve disease and requires higher surveillance and more non-invasive tests than available in most outpatient clinics. These tests include specialist echocardiography, blood BNP level and exercise testing. Furthermore, decisions about the design of replacement heart valve or whether repair of a mitral valve is feasible are increasingly involved. For these reasons discussion papers have called for at least one cardiologist specialising in valve disease at every large hospital.
Our valve clinic evolved from a research clinic and had two main components, a second opinion service run by a cardiologist specialising in valve disease and a follow-up clinic run by a sonographer and nurse. The advantages of a specialist linked valve clinic are expected to be:
Our valve clinic evolved from a research clinic and had two main components, a second opinion service run by a cardiologist specialising in valve disease and a follow-up clinic run by a sonographer and nurse. The advantages of a specialist linked valve clinic are expected to be:
Specialist Valve Clinic
| • | Better surveillance and timing of surgery leading to better outcomes for the patient |
| • | Better decisions about surgery including type of valve and repair vs replacement including referral to a surgeon appropriate for the type of surgery indicated |
| • | Convenience for the patient with all necessary tests performed at the same time |
| • | Concentration of information and potentially other services e.g. dental surgeon, rehab nurse, pre-surgical counselling |
| • | Facilitation of observational and interventional research |
| • | Reduction in unnecessary investigations |
| • | Reduction in the need for SpR attendance |
| SUMMARY OF ROLES | |
| New visits and formulation. Referral for surgery if necessary | Cardiologist |
| Assessment of follow-up patient with alerts. Referral for surgery as necessary | Cardiologist |
| Follow-up history | Nurse / Sonographer |
| Performing exercise test | Exercise physiologist |
| Supervision of exercise test | Nurse / sonographer / cardiologist |
| Echocardiogram | Sonographer / cardiologist |
| BNP test | Nurse / cardiologist / sonographer |
There are some cautions:
(1)The clinic sonographers and nurses are experienced and highly qualified. We ensured appropriate training before starting the clinics and confirmed that their clinical assessment skills were accurate. A devolved clinic would not necessarily be safe with more junior staff.
(2)More cases than anticipated, about 12%, require advice from a cardiologist. Ideally the clinic needs to be supervised by a cardiologist.
(3)Although a history can be taken while scanning a case, a surveillance clinic appointment is still longer than a conventional clinic. The slots are 60 minutes long.
(4)The valve clinic obviously reduces sonographer capacity in other areas unless new staff are taken on.
(1)The clinic sonographers and nurses are experienced and highly qualified. We ensured appropriate training before starting the clinics and confirmed that their clinical assessment skills were accurate. A devolved clinic would not necessarily be safe with more junior staff.
(2)More cases than anticipated, about 12%, require advice from a cardiologist. Ideally the clinic needs to be supervised by a cardiologist.
(3)Although a history can be taken while scanning a case, a surveillance clinic appointment is still longer than a conventional clinic. The slots are 60 minutes long.
(4)The valve clinic obviously reduces sonographer capacity in other areas unless new staff are taken on.
