State of the Art Technology Bioprosthetic Aortic Heart Valve
Heart valve disease: a journey of discovery
Abstract
In the centenary year of the British Cardiovascular Social club (BCS), this review article outlines the influence of Uk cardiologists and surgeons on the field of heart valve disease, many of whom tin can rightly claim 'world firsts' in the field. From the clarification of endocarditis every bit we know it today at the turn of the 20th century, to the first mitral valvotomy, middle valve replacement and invention of the Ross procedure. These advances take transformed the outlook of patients with symptomatic valve disease from palliation and sure death to curative treatment and near normal life expectancy. Transcatheter aortic valve implantation (TAVI) was adopted early in the UK, and thanks to the comprehensive national database, the UK TAVI registry is ane of the world's largest, contributing real-world patient data to inform clinical practice. The more recent concepts of 'Heart Valve Centres of Excellence' and specialist valve clinics accept been developed by the BCS-affiliated British Heart Valve Gild which continues to drive improved standards for patients with centre valve affliction. The next 100 years will no doubt be equally thrilling in terms of innovation for center valve disease, with artificial intelligence, transcatheter therapies and cutting-border engineering science continuing to improve patient intendance and clinical outcomes.
- middle valve prosthesis implantation
- eye valve diseases
- endocarditis
- transcatheter aortic valve replacement
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- eye valve prosthesis implantation
- centre valve diseases
- endocarditis
- transcatheter aortic valve replacement
The British Cardiovascular Society (BCS) is the globe'due south oldest cardiovascular professional social club. From its genesis as the Cardiac Club in 1922 to the large internationally renowned establishment that it has become in 2022, heart valve disease has always played a prominent role—herein, we outline the impact that British cardiologists and surgeons take fabricated in advancing diagnosis and treatment.
The pioneers
From the early days, British cardiologists and surgeons took centre phase in the history of eye valve affliction (figure 1). Dr James Hope (1801–1841), a Mancunian cardiologist, was an early adopter of cardiac auscultation later the invention of the stethoscope in 1816 and described the murmurs of aortic and mitral valve disease for the beginning time (with aortic regurgitation initially described every bit 'Hope's murmur'). His main research findings were derived from experiments on the exposed heart of a stunned donkey. Auscultation was a skill feared by many physicians of the time, and he dedicated his career to demonstrating the new technology to colleagues and students.1 Shortly after, the Irish md, Corrigan, described the arterial pulsations of aortic regurgitation, and Sir Thomas Watson (1792–1882), an English Dr., likened the palpable radial 'water-hammer' pulse to a Victorian toy of the same name in 1842.two
Cardiology was a specialty in its infancy at the turn of the 20th century, and plans past Sir James Mackenzie for a run into upwardly of 'like-minded physicians interested in middle disease' were delayed by the onset of the Groovy War. Many among the huge swathes of troops returning to Britain from 1914 onwards had illness requiring evaluation by cardiologists. Louse-borne Bartonella infection (known then every bit 'Trench Fever') was very common and led to endocarditis in some, alongside the medically unexplained syndrome of 'Soldiers' Heart'. A regime-led physician gathering to hash out evaluation of these troops resolved that those with an interest in cardiology should continue to meet.
The 'Cardiac Gild' was founded by 15 members in 1922, including Carey Coombs—pioneer of rheumatic center illness, writer in 1924 of the first comprehensive English monograph on the topic,iii and first to depict the rumbling mid diastolic murmur of acute rheumatic valvulitis that now bears his name. The murmur characteristically diminished and and so disappeared as acute carditis and valve inflammation resolved, affirming the importance of meticulous and frequent examination of all patients with acute rheumatic fever.
Largely missing from the history books is the remarkable story of Sir Henry Sessions Souttar—a British surgeon based at the London Hospital and the get-go to draw mitral commissurotomy, performed on a 15-year-onetime daughter, Lillian H from Bethnal Green, in 1925.4 His bravery to perform such a daring process was remarkable and some doctor colleagues suggested that he may be prosecuted for manslaughter if the patient did not survive, while others commented that an adverse outcome should at to the lowest degree prompt resignation. In his 1925 BMJ publication, he outlined insertion of a finger via the left atrial appendage to dilate the stenosed rheumatic heart valve—the first description of blind open up centre surgery.5 Lillian survived a further seven years afterwards the operation, finally succumbing to cognitive embolism. When asked why he did not repeat the process given its relative success, he volunteered that he was never referred another patient, physicians declaring it 'all not-sense'vi and failing to believe that the symptoms of mitral stenosis could be ascribed to a simple obstruction between the left atrium and ventricle. Indeed, Carey Coombs was amidst these sceptics, declaring that 'the performance can never get a general method of treatment for a disease of which the mitral lesion is but one characteristic—to say nothing of the technical difficulties attention surgical approach to this structure'.7 Sir Thomas Lewis was also dismissive, writing xx years after that 'although many symptoms may be complained of past the patients suffering of mitral stenosis, there are none that can be ascribed properly and usefully to this deformity of the valve'.7 Souttar became a BCS fellow member and eventually spoke almost the operation at the 1957 Autumn Meeting. Meanwhile, valve surgery was not farther attempted until 1947, when Thomas Sellors reported direct relief of pulmonary stenosis in a 20-year-former human with Tetralogy of Fallot at the Middlesex Infirmary, London,8 followed past closed mitral commissurotomy performed by Lord Russell Brock at Guy'southward Hospital, London in 1948.6 The aforementioned year, Brock joined with Cardiac Club Secretary, Dr Maurice Campbell, to grade the 'Peacock Club' at Guy'southward Hospital post-obit a visit to the unit of measurement by Blalock (of Blalock-Taussig shunt fame) to educate on all matters apropos built heart disease.9 Over 30 years subsequently in 1984, the first transcatheter mitral balloon valvuloplasty was performed by Inoue using his innovative airship catheter,7 and vi years afterwards, Wilkins published his mitral echocardiographic score in the British Middle Periodical, paving the fashion for electric current choice algorithms.ten
Scarcely reported in the literature is the worlds' starting time mitral valve replacement at the City General Hospital in Sheffield by cardiothoracic surgeon, Mr Judson Chesterman. The Perspex valve was designed on principles used in automotive pattern and implanted during beating eye surgery with de-airing achieved via a syringe and needle.11 The design was flawed and valve embolism proved fatal, merely futurity modifications of the valve more closely resembled those of Albert Starr who implanted the Starr-Edwards valve seven years afterward in the Usa. Alfred Gunning (an Oxford University scientist) donated freeze-stale aortic valves to Donald Ross who successfully implanted them in a patient with aortic stenosis at Guy's Hospital in 1962. This homograft procedure was the commencement subcoronary bioprosthetic aortic valve replacement in the world and took place prior to availability of the Starr-Edwards valve in the Britain.12 Ross had not had the opportunity to endeavour the technique in an animal model, but used the experimental subcoronary homograft as a salvage procedure following all-encompassing destruction of the native aortic valve following attempted leaflet decalcification—the patient subsequently survived 3 years.13 The freeze-drying method of homograft preparation was subsequently modified to accost the problem of premature degeneration, while Ross built on this early experience to excogitate the Ross procedure that is all the same performed across the globe. Similarly, Hugh Bentall and Antony De Bono described treatment of aortic root aneurysm with a composite valve-graft and side-to-side coronary anastomosis in 1968, an operation even so considered the aureate standard over 50 years subsequently.fourteen
The curious instance of Benjamin Britten, the great English language composer, highlights the perilous state of those with valve affliction in this era. Although initial rumours suggested he suffered with syphilitic aortic affliction, his functioning report suggests a degenerative aetiology. The burden of disease was so bang-up that it was said past Sir Peter Pears, the English tenor, that the effort of composing the opera 'Decease in Venice' was killing him. Indeed, the tempo of the clarinet in the opening scenes may reverberate his underlying atrial fibrillation or ventricular ectopy at the fourth dimension. Ross performed his eponymous procedure on Britten in 1973 only surgery was complicated by a stroke and Britten never fully recovered, passing away 3 years later of congestive cardiac failure.fifteen
Marian Ionescu was a surgeon based at Leeds General Infirmary with a lifetime obsession apropos the development of prosthetic heart valves. In 1967, he implanted a porcine aortic valve with a Teflon cloth collar that evolved over time to a Dacron-covered titanium frame. Durability was poor owing to the formaldehyde preservation technique and attempts to address this using fascia lata harvested from the patients' ain thigh suffered like issues in the loftier-pressure left middle organisation. Glutaraldehyde-treated bovine pericardium was associated with greater success and this valve was marketed commercially as the 'Ionescu-Shiley' pericardial xenograft. Although widespread uptake was again hampered by poor longevity resulting from torn leaflets, this extensive piece of work made a major contribution to advances in bioprosthetic valve technology.16
New and former challenges
The modern history of heart valve disease can be considered in four discrete phases (figure 2). Acquired heart disease was the focus at the turn of the 20th century, involving the as-yet untreatable conditions of infective endocarditis, syphilitic aortic disease and astute rheumatic carditis (and ensuing rheumatic heart affliction) that gave rise to a myriad of symptoms and signs, and accompanying eponymous syndromes ascribed to British cardiologists.
Antibiotics were introduced in the mid-20th century and allowed the handling of endocarditis, syphilis, streptococcal throat infection and acute rheumatic carditis,17 while the concurrent advent of cardiac surgery meant that curative treatment was all of a sudden available for those previously on a palliative trajectory. The development of transcatheter balloon therapies to treat pliable, non-calcified stenotic heart valves came later in this period, with widespread application of balloon mitral and pulmonary valvuloplasty.18 Stuart Shaw and colleagues at the Western General Hospital in Edinburgh subsequently extended this feel to an inoperable, frail population with 'burnt out' calcific rheumatic mitral stenosis, a risky business which occasionally led to Inoue airship rupture (figure three).19
The new millennium has been dominated by degenerative valve disease affecting a fragile, more elderly population that may not survive open heart surgery, paving the way for an age of further innovation. The widespread awarding of transcatheter therapies has ironically bought the treatment of heart valve disease 'full circle' from the days of closed mitral valvotomy and these new techniques accept in turn led to renewed interest in aetiology, pathogenesis and natural history. In the United kingdom, much of this enquiry has been led past Professors David Newby (BCS Mackenzie Medal 2018) and Marc Dweck (BCS Immature Inquiry Workers Prize 2012, Michael Davis Early Career Laurels 2016) at Edinburgh Academy, focusing on aortic valve inflammation and the myocardial impact of aortic stenosis.20 21
Endocarditis: modern approaches to an ancient disease
Although endocarditis was probably first described in 1646 in France, Matthew Baillie (1761–1823), a London-based physician and pathologist, made the first diagnosis of 'rheumatic carditis' in 1797, followed by reports of the embolism of infected vegetations in 1852 past William Senhouse Kirkes, a physiologist at St Batholomew's Hospital, London.22 Sir Samuel Wilks, the '1000 erstwhile human being' of British medicine and physician to Queen Victoria, was historic for many medical achievements, including the first association of fatal arterial pyaemia with cardiac vegetations in 1882 (usually mistaken for typhoid at the fourth dimension),23 while Sir William Osler's Goulstonian lectures on 'cancerous endocarditis' at the Royal College of Physicians in 1885 describing the clinical and postmortem features of the disease remain famous to this day.24 Thomas Horder and HJ Starling were founding members of the Cardiac Club and leading experts in infective endocarditis (figure 4), and Horder delivered a topical lecture on the subject at the inaugural guild meeting in 1922. The more than recent recognition that loftier-quality intendance for these complex patients requires input from many different specialty-led UK endocarditis specialists to propose the concept of the 'endocarditis squad'.25 The effectiveness of this approach was confirmed in a written report from Kings' College Infirmary, London, demonstrating a 24% reduction in bloodshed afterwards the introduction of this model of care.26
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Figure 4
Founding members of the cardiac society and leading authorities in valve disease. Left hand panel: Sir Thomas Horder (1871–1955). Right hand panel: Dr Henry J Starling (1873–1950). Archive photos reproduced with permission from the British Cardiovascular Society Archives.
In no other country in the world has the topic of antibiotic prophylaxis for endocarditis been more hotly debated. The 2008 Overnice guidelines recommending cessation of the practice in all patients (regardless of underlying risk) provoked a backlash from the cardiology community, and inevitable dissent from patients with longstanding middle valve disease who felt uneasy with such a dramatic modify in exercise.27 Adding fuel to the fire (and perchance creating more questions than answers), a subsequent UK epidemiological study published in the Lancet demonstrated a significant rise in the incidence of endocarditis coincident with the guideline publication.28 Although lack of microbiological data prevented a causal association, the wording of the NICE guidelines was changed 2 years later to afford more flexibility with clinical decision-making. This compromise was reinforced past a 2018 NICE guideline implementation written report from the Scottish Dental Clinical Effectiveness Programme (SDECP) and endorsed by the BCS and the British Heart Valve Society (BHVS).29
The ascension and rising of transcatheter aortic valve implantation (TAVI)
The significant bear on of transcatheter intervention on the treatment of pulmonary and mitral stenosis did not translate to the aortic valve as a upshot of rapid restenosis, rendering balloon aortic valvuloplasty a predominantly palliative process in those unfit for conventional valve surgery.thirty Yet, this did not deter Henning Andersen and Alain Cribier, the pioneers of transcatheter aortic valve implantation based in Denmark and France, respectively. Early prototypes developed in animate being models during the 1990s were plagued with problems, including coronary occlusion and valve embolism. Early publications were rejected past leading journals with comments that the concept was 'too depression a priority for publication'31 and the medical device industry reacted with cynicism. However, the new millennium saw Cribier's squad perform the first successful animal process followed shortly by the beginning-in-human implant in 2002.32 A decade later, Cribier delivered the BCS 2013 Paul Wood Lecture in recognition of his contribution to the field.
The Britain adopted the procedure early and the TAVI acronym was coined by Simon Redwood, Martyn Thomas and Jan Kovac (all high-volume operators) in time for publication of the PARTNER 1B trial,33 although mysteriously (and inexactly) translated to 'TAVR' in the ensuing PARTNER 1A trial.34 The starting time UK procedure was performed at Glenfield Hospital, Leicester, in 2007, and the start valve-in-valve procedure at Kings College Hospital, London in 2009. Indeed, almost 400 procedures had already been performed by the finish of 2008, demonstrating the enormous potential of the new procedure.35 Edifice on the UK's heritage of registry information and the advantages offered past unique NHS identifiers, the UK TAVI registry was rapidly established by the British Cardiovascular Intervention Guild (BCIS) and the Guild of Cardiothoracic Surgeons (SCTS), and swiftly became one of the earth's largest TAVI registries, providing valuable insights into real-earth patient outcomes.36 Building on this collaboration, the UK TAVI trial has recently provided important evidence supporting the utilise of TAVI in younger, low-adventure patients and endorsed the Heart Squad arroyo to case option.37
Innovation in an economically constrained environment
The OxVALVE study was the beginning to highlight the emerging epidemic of valve disease in the ageing Great britain population and demonstrated that mitral regurgitation is the virtually common valve lesion, affecting >20% of adults aged >65 years.38 Mitral valve beefcake and pathophysiology are far more complex than the aortic valve and the development of transcatheter technologies has proved to exist a pregnant interventional and engineering science claiming. Adopting a strictly evidence-based arroyo, the United kingdom has been a irksome adopter of transcatheter mitral therapies while awaiting the outcome of a prolonged NHS 'Commissioning Through Evaluation' process. Recommendations were finally provided in 201939 and proved consistent with the conclusions of the landmark EVEREST trial published 10 years previously.40 Despite these challenges, the team at St Thomas' Hospital, London performed i of the world's first transcatheter mitral valve replacements in 2012 and go along to drive the innovation agenda in conjunction with other groups in Brighton, Leeds, Oxford and London.41
Sub-specialism and models of care
Management of eye valve affliction was the domain of the 'general cardiologist' for decades but more recent advances in imaging and expansion of treatment options have made the field increasingly complex, requiring subspecialists with experience in investigation, evaluation and treatment. Dedicated heart valve clinics were pioneered by John Chambers at Guy's Hospital, London, facilitating standardised care and improved outcomes. Elaboration of this model to incorporate 'Hub and Spoke' arrangements beyond geographical networks supporting specialist 'Heart Valve Centres' is now strongly recommended within European and US do guidelines.42 43 These guidelines further emphasise a patient-centred multidisciplinary 'Centre Team' approach, as endorsed by the BCS collaborative document outlining standards for multidisciplinary meetings44 and NHS England 'Getting it Right First Time' Cardiology report prepared past BCS by-Presidents, Sarah Clarke and Simon Ray.45
Groups linked to the BCS take made meaning contributions to the improved care of middle valve affliction in the UK. The British Cardiovascular Intervention Society and British Society of Echocardiography were affiliated to the BCS in 1987, while the BHVS was established in 2010 to represent all professional groups involved in the care of patients with centre valve disease. Recently, BHVS publications include a blueprint framework for the commitment of eye valve services in the UK (figure 5)46 and guidance for the management of patients with eye valve affliction during the COVID-nineteen pandemic.47
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Figure 5
Key components of specialist heart valve clinics extracted with permission from British Heart Valve Gild design endorsed past British Cardiovascular Guild.46 CMR, cardiovascular magnetic resonance; CT, computerised tomography; PET, positron emission tomography.
Future challenges and directions
Renewed interest in middle valve affliction over the past twenty years has led to an exciting era of innovation and enquiry. Furthermore, the recent pandemic has accelerated advances in management, with increased focus on transcatheter technology,48 app-based engineering science, virtual consultations and Heart Team meetings, electronic stethoscopes, and wearable technology outlined in the recently published BCS 'Future of Cardiology' report.49
Several ongoing UK-based trials promise to farther our understanding of the potential benefits of before treatment of valve illness and seem likely to bear on on international guideline recommendations within the next decade. Of note, the EASY-AS report led by Gerry McCann in Leicester aims to investigate the role of surgical or transcatheter intervention in asymptomatic severe aortic stenosis,50 while the EVOLVED study led by Marc Dweck in Edinburgh is evaluating the employ of a screening algorithm incorporating ECG, serum and MRI biomarkers to triage patients with asymptomatic astringent aortic stenosis and decide those who benefit almost from early intervention.51
The need for lifelong anticoagulation is crushing for patients with mechanical valves while bioprosthetic valves take limited immovability, particularly in younger patients. Development of a bioprosthetic valve that would last a lifetime would have huge impact, avoiding the need for repeat interventions and the clinical risks and considerable morbidity associated with lifelong anticoagulation. A design with meaning hope is the Poli-Valve, a polymer-based valve with potential immovability of up to 25 years under development by teams of biomaterial engineers, computational modellers and cardiologists at Bristol and Cambridge Universities funded by the British Heart Foundation.52
James Promise, the original exponent of cardiac auscultation, would be most impressed with the resurgence of the stethoscope. The ancient fine art of cardiac auscultation may be nearly to experience a renaissance in the course of 'Jade', a low-cost bogus intelligence-enabled digital stethoscope developed at Cambridge University.53
Challenges remain despite these heady advances. The global healthcare burden of eye valve disease is increasing inexorably with widespread socioeconomic and geographical disparities, while the outlook for symptomatic patients remains dismal, with prognosis worse than many cancers.54 The urgent attention of clinicians, healthcare economists, public-health specialists, global healthcare agencies and the cardiovascular device industry is required to ensure that future histories remain positive.
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