Routine Follow-up for Patients With Prosthetic Valves
Routine Follow-up for Patients With Prosthetic Valves
We found that one-third of patients do not receive regular follow-up after valve replacement either in the community or at a hospital. International guidelines stipulate annual follow-up by a cardiologist after valve implantation. However, the hard event rate is low in patients with normally functioning valves without significant cardiac comorbidity, leading to the suggestion that these can be discharged provided that rapid access to a cardiologist is available should symptoms develop. This could be ensured using a telephone help-line.
We found no obvious difference in hard events between patients who did and did not receive serial follow-up after implantation of an OnX valve. However, this was not a formal comparison of the two strategies and we would have expected a significant difference had we investigated valves shown to be prone to early failure. Furthermore, a much larger proportion of patients had less severe problems for which serial follow-up would still have been likely to reduce the risk of a hard event. This follow-up can be devolved to a nurse-led clinic freeing the cardiologist to see new patients or those that have clinical problems. For example, the nurse in our clinic resolved problems with INR or rhythm control, discussed dental surveillance and gave lifestyle advice (Table 1). As many as one-third of the OnX valve patients never saw a dentist, while all guidelines stipulate the need for regular surveillance to prevent endocarditis. Reminding about dental issues, and perhaps helping arrange a dentist, may arguably be one of the most important roles of a nurse-led clinic. Prosthetic valve endocarditis has a high mortality and there is evidence that antibiotic prophylaxis is effective. Despite this the National Institute for Health and Clinical Excellence (NICE) guidelines recommend avoiding antibiotic prophylaxis for any dental work. Our observation that the NICE guideline is not followed in two-thirds of patients suggests that a registry may establish the efficacy of antibiotics in preventing prosthetic valve endocarditis without the need for a randomised-controlled trial.
There are other models of valve surveillance clinic that are solely nurse led. Based on our experience of providing a 'one-stop' valve clinic, we believe that a valve clinic should be multi-disciplinary and include a cardiologist and sonographer, since 10% of visits required a cardiologist opinion and 4% an echocardiogram. This allows any problems identified to be promptly managed, usually within that clinic visit. However, in normally functioning mechanical valves and biological valves five years and earlier after implantation, routine echocardiography is not recommended, and devolving follow-up from a registrar to a specialist nurse is expected to save requests for unnecessary echocardiograms. Therefore, having a nurse-led component in a valve clinic provides long-term monitoring of the valve and general care for a larger number of patients than can be seen by a cardiologist. Arguably, a GP could provide the surveillance, but in practice this does not usually occur. Many problems detected by the nurse are clinically minor but could reduce the risk of a hard event, e.g. dental advice.
Discussion
We found that one-third of patients do not receive regular follow-up after valve replacement either in the community or at a hospital. International guidelines stipulate annual follow-up by a cardiologist after valve implantation. However, the hard event rate is low in patients with normally functioning valves without significant cardiac comorbidity, leading to the suggestion that these can be discharged provided that rapid access to a cardiologist is available should symptoms develop. This could be ensured using a telephone help-line.
We found no obvious difference in hard events between patients who did and did not receive serial follow-up after implantation of an OnX valve. However, this was not a formal comparison of the two strategies and we would have expected a significant difference had we investigated valves shown to be prone to early failure. Furthermore, a much larger proportion of patients had less severe problems for which serial follow-up would still have been likely to reduce the risk of a hard event. This follow-up can be devolved to a nurse-led clinic freeing the cardiologist to see new patients or those that have clinical problems. For example, the nurse in our clinic resolved problems with INR or rhythm control, discussed dental surveillance and gave lifestyle advice (Table 1). As many as one-third of the OnX valve patients never saw a dentist, while all guidelines stipulate the need for regular surveillance to prevent endocarditis. Reminding about dental issues, and perhaps helping arrange a dentist, may arguably be one of the most important roles of a nurse-led clinic. Prosthetic valve endocarditis has a high mortality and there is evidence that antibiotic prophylaxis is effective. Despite this the National Institute for Health and Clinical Excellence (NICE) guidelines recommend avoiding antibiotic prophylaxis for any dental work. Our observation that the NICE guideline is not followed in two-thirds of patients suggests that a registry may establish the efficacy of antibiotics in preventing prosthetic valve endocarditis without the need for a randomised-controlled trial.
There are other models of valve surveillance clinic that are solely nurse led. Based on our experience of providing a 'one-stop' valve clinic, we believe that a valve clinic should be multi-disciplinary and include a cardiologist and sonographer, since 10% of visits required a cardiologist opinion and 4% an echocardiogram. This allows any problems identified to be promptly managed, usually within that clinic visit. However, in normally functioning mechanical valves and biological valves five years and earlier after implantation, routine echocardiography is not recommended, and devolving follow-up from a registrar to a specialist nurse is expected to save requests for unnecessary echocardiograms. Therefore, having a nurse-led component in a valve clinic provides long-term monitoring of the valve and general care for a larger number of patients than can be seen by a cardiologist. Arguably, a GP could provide the surveillance, but in practice this does not usually occur. Many problems detected by the nurse are clinically minor but could reduce the risk of a hard event, e.g. dental advice.
