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Welcome to our new Valve Team Newsletter. The aim is to keep you updated with what’s happening locally at UHCW, and if there are any national updates.

If you have any stories you would like to share, please get in touch via AorticValveService@uhcw.nhs.uk.

Please also let us know if there is any specific information you would like updates on.

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In March 2023 we performed our first ever Transcatheter Edge to Edge Repair (TEER) procedure. This is offered to patients with severe Mitral Regurgitation, who have been deemed too high risk for surgical intervention. We now run a specific Mitral Valve MDT once a month where all patients are discussed.

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In 2023 our Heart Valve Clinical Nurse Specialist, Lauren Deegan was approached to join a group of experts in the field of Heart Valve Disease.

Meetings were held to discuss the health gender gap for treating Aortic Stenosis (which is not only an issue in the UK but globally). It has been found that if you are a woman with severe Aortic Stenosis, you are less likely to get treatment, compared to a man. (https://openheart.bmj.com/content/10/2/e002373)

As a group they looked at the barriers to diagnosis and treatment, faced by patients and healthcare professionals.

At the end of April 2023, Solutions were presented to MPs via the All Party Parliamentary Group for Women’s Health, and a Call to Action was raised for the government to implement the solutions.

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UHCW Aortic programme - managing patients with diseases of the thoracic aorta

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UHCW Aortic programme - managing patients with diseases of the thoracic aorta

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The aortic programme at UHCW NHS Trust, manages patients with diseases of the thoracic aorta, providing comprehensive care for patients with complex aortic disease.   It treats patients with aortic valve disease, aortic root affection, ascending aortic and arch aneurysms. In collaboration with our vascular surgeons, we are also involved in treating patient with proximal descending aortic pathology. Besides elective aortic work, the unit caters to acute aortic pathology which involves treating acute Type ‘A’ dissections. The team provides 24-hour service in managing acute aortic pathology, click on the picture to find out more.

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From Jan 1st to December 31st we have performed 155 TAVI procedures.

35% were inpatients or transfers from other hospitals.

The median wait for electives (referral to treatment) was 5 months, which compares favourably to the regional median wait. Capacity has been increased in 2024 to improve this further.

4 of our patients that had critical Aortic Stenosis underwent CT, Clinic appointment and TAVI in less than 3 weeks. If you are concerned about a particular patient, please get in touch with us so that we can escalate their procedure.

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Frailty Score - click on the picture to enlarge

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Referring for TAVI?
Please include:
- Current symptoms
- PMH
- Clinical fraility score to assist with MDT discussions
- Attach echo report (and send CD if not using PACS)
- Angiogram not required unless the patient has angina
- Lung Function not required as local anaestetic used

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Interesting Case - 81-year-old man with breathlessness and angina. PMH of triple-vessel CABG plus St Jude Epic 21 mm bioprosthetic aortic valve replacement (AVR) surgery 7 years prior.

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Interesting Case - 81-year-old man with breathlessness and angina. PMH of triple-vessel CABG plus St Jude Epic 21 mm bioprosthetic aortic valve replacement (AVR) surgery 7 years prior.

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Imaging of prosthetic cardiac valves using echocardiography can be significantly limited by reverberation and shielding artefacts, degrading leaflet assessment.

Degenerative calcification, pannus and thrombus are key differentials for bioprosthetic valve obstruction and can be challenging to assess on echocardiography, X-ray fluoroscopy and cardiovascular MRI.

Cardiac CT allows accurate non-invasive assessment of prosthetic valves with high spatial resolution. It allows excellent assessment of leaflet mobility, assessment for calcification, pannus and thrombus, visualisation of complications arising from endocarditis (abscesses, dehiscence) and also permits left ventricular and coronary artery assessment within the same study.

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Description

An 81-year-old man was referred to the cardiology clinic with breathlessness and angina. His history included triple-vessel coronary artery bypass graft (CABG) plus St Jude Epic 21 mm bioprosthetic aortic valve replacement (AVR) surgery 7 years prior.

Transthoracic echocardiography (TTE) demonstrated severely elevated Doppler AVR velocities (VMax 4.7 m/s) and severe AVR stenosis (valve area 0.7cm ²). This was the suspected cause of symptoms, and transfemoral valve-in-valve AVR valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) was being considered. However, TTE image quality was suboptimal due to echocardiographic windows and valve echogenicity, precluding accurate leaflet assessment ( figure 1A-D ). Transoesophageal echocardiography corroborated TTE findings (VMax 5.5 m/s) but failed to delineate the mechanism of AVR restriction ( figure 1E-H ). Degenerative leaflet calcification was evident on echocardiography, however echogenicity around the sewing ring prevented distinction between calcification and pannus, and ultrasound dropout precluded thrombus exclusion.

Invasive coronary angiography confirmed severe native coronary disease and patency of two bypass grafts, however the third graft could not be cannulated. Cardiovascular MRI confirmed inferolateral infarction, mild left ventricular systolic dysfunction and significant AVR stenosis. However, high antegrade AVR flow velocities and metallic valve stents resulted in signal loss and failure to delineate the mechanism of AVR restriction due to flow and susceptibility artefacts, respectively.

Given the limitations of echocardiography and angiography, a prospectively gated cardiac CT scan was performed (). Its high spatial resolution and ability to characterise tissue based on CT absorption (attenuation) characteristics allowed accurate non-invasive AVR and coronary artery assessment. Absence of lung parenchyma and pulmonary embolic disease, and excellent patency of all bypass grafts were confirmed. Circumferential low attenuation (125 Hounsfield units; HU) around the underside of the sewing ring was consistent with pannus. There was accumulation of a large area of very low attenuation material (35 HU) over the non-coronary cusp and adjacent sewing ring segment. This was in keeping with significant thrombus burden causing symptoms due to leaflet restriction and orifice encroachment.

VIV-TAVI workup was postponed, and a repeat CT study after 3 months of warfarinisation confirmed thrombus resolution. Residual thin circumferential pannus and mild non-calcified degenerative leaflet thickening were confirmed (). The patient was rendered asymptomatic with, corroboratively, significantly reduced TTE AVR velocities (VMax 3.8 m/s).

Cardiac CT was the only modality accurately assessing the AVR, allowing appropriate therapy to be directed and preventing redo AVR surgery. Mild residual asymptomatic AVR stenosis due to mild leaflet degeneration and pannus was confirmed. The patient remains asymptomatic 6 months later on warfarin.

Prosthetic valve imaging using echocardiography can be limited by reverberation (reflective) and shielding (signal loss) artefacts from metal components which can also be challenging to differentiate from degenerative calcification. X-ray fluoroscopy can demonstrate leaflet mobility but is limited by its angle dependence and inability to visualise pannus and thrombus. Cardiac CT allows excellent non-invasive prosthetic valve assessment due to excellent spatial resolution and visualisation of leaflet motion. CT attenuation characteristics (HU) allow distinction between the key differentials of valve obstruction-thrombus and pannus-which can be notoriously challenging using echocardiography, X-ray fluoroscopy and cardiovascular MRI. CT also provides simultaneous excellent native coronary artery, CABG, aorta and pulmonary arterial imaging. Accurate CT aortic root assessment allows unrivalled assessment of endocarditic complications, including dehiscence, abscess, fistula and aneurysm formation. Cardiac CT is a valuable but currently underused tool in the multimodality imaging assessment of prosthetic cardiac valves, despite widespread availability.

'The CT scan helped the doctors work out why I was getting short of breath and treat me without me having to have another operation.'

Imaging of prosthetic cardiac valves using echocardiography can be significantly limited by reverberation and shielding artefacts, degrading leaflet assessment.

Degenerative calcification, pannus and thrombus are key differentials for bioprosthetic valve obstruction and can be challenging to assess on echocardiography, X-ray fluoroscopy and cardiovascular MRI.

Cardiac CT allows accurate non-invasive assessment of prosthetic valves with high spatial resolution. It allows excellent assessment of leaflet mobility, assessment for calcification, pannus and thrombus, visualisation of complications arising from endocarditis (abscesses, dehiscence) and also permits left ventricular and coronary artery assessment within the same study.

Footnotes

Contributors: All authors were heavily involved in production of the manuscript and images, and then finalising approval of the version published. All authors are agreeable to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated and resolved. JNK: planning, conception and production of manuscript/images; clinical management of patient; undertook cardiac imaging (TTE, TOE, CMR, CT) and interpretation of data. BD: review and editing of manuscript; involved in cardiac imaging (CT) and interpretation of data. SV: review and editing of manuscript; clinical management of patient; involved in cardiac imaging (echo) and interpretation of data. BR: review and editing of manuscript; clinical management of patient; involved in cardiac imaging (CMR, CT) and interpretation of data.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Cardiac CT provides uniquely accurate and comprehensive assessment of bioprosthetic aortic valve stenosis

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An 81-year-old man was referred to the cardiology clinic with breathlessness and angina. His history included triple-vessel coronary artery bypass graft (CABG) plus St Jude Epic 21 mm bioprosthetic aortic valve replacement (AVR) surgery 7 years prior. Transthoracic echocardiography (TTE) demonstrated severely elevated Doppler AVR velocities (VMax 4.7 m/s) and severe AVR stenosis (valve area 0.7cm 2).

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AorticValveService@uhcw.nhs.uk

Structural Heart Clinical Nurse Specialists:

Lauren Deegan

02476 965785 or lauren.deegan@uhcw.nhs.uk

Joanne Keane

02476 965785 or Joanne.Keane2@uhcw.nhs.uk

Secretary Julie Jupp: 02476 965670

Cardiology Consultants (TAVI operators):

Dr T. Rajathurai: 02476 965003

thirumaran.rajathurai@uhcw.nhs.uk

Dr L. Tapp: 02476 965703

luke.tapp@uhcw.nhs.uk

Dr N. Gangil: 02476 965713

nishant.gangil@uhcw.nhs.uk

Cardiology Consultant (Imaging)

Dr J. Khan: 02476 965670

jamal.khan@uhcw.nhs.uk

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Secretary Yvonne Tennant: 02476 965678

Cardiothoracic Liaison Nurses: 02476 965803

cardiacliaisonteam@uhcw.nhs.uk

Cardiothoracic Surgeons:

Mr Uday Dandekar:

uday.dandekar@uhcw.nhs.uk

Mr Thomas Barker:

thomas.barker@uhcw.nhs.uk

Mr Sendhil Balasubramanian: sendhilK.Balasubramanian@uhcw.nhs.uk

Mr Massimiliano Codispoti:

massimiliano.codispoti@uhcw.nhs.uk

Mr Jain Bhaskara-Pillai:

Jain.BhaskaraPillai@uhcw.nhs.uk

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Have you seen the new guidance?

In February 2023, NHS England stated that we can now offer TAVI to patients with intermediate AND low surgical risk. This interim position aims to alleviate the pressures on local systems in supporting elective performance and is dependent on the ability and capacity of systems to deliver either option.

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NHS England » Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Replacement (SAVR) for symptomatic, severe aortic stenosis (adults) to support elective performance