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Welcome to the European Society of Cardiology. Our mission: to reduce the burden of cardiovascular disease in Europe
 

Promoting heart valve clinics to facilitate risk stratification and ‘watchful waiting’ 

Topics: Non-invasive imaging: Echocardiography, MR/CT, Nuclear
Date: 14 Dec 2013
Despite being just 38, Raphael Rosenhek has already made his name as an international expert in aortic stenosis and mitral regurgitation, pioneering the field of risk stratification for valvular heart disease and promoting the concept of ‘watchful waiting’. Now Chairperson-elect of the ESC Nucleus of the Working Group (WG) on Valvular Heart Disease, Rosenhek plans to champion the concept of dedicated heart valve clinics and forge stronger links with the EACVI.

Raphael Rosenhek‘Echocardiography provides the cornerstone for valve disease. It’s key for establishing aetiology, quantifying severity, studying progression, determining repercussions on the ventricle and assessing the likelihood of successful repair,’ says Rosenhek, an echocardiographer who directs the Heart Valve Clinic at the Medical University of Vienna.

The Valvular Heart Disease WG and EACVI, he says, have a real synergy. ‘Working together allows us to achieve more than the sum of either group alone.’
Initially Rosenhek, who grew up in Vienna, found it hard to choose between physics and medicine. This dual interest was inspired by his physician father and his great uncle Walter Kohn, who received the 1998 Nobel Prize for Chemistry in recognition of his role in the ‘development of density functional theory’. Rosenhek solved his dilemma by studying both subjects in parallel, but at the end of his first year at the University of Vienna opted for medicine. ‘Medicine had more of a human dimension which was really important to me,’ he says.

This interest in people comes to the fore when we get side tracked from valves to talk about his family’s experiences in World War II. Kohn and his sister Minna (Rosenhek’s grandmother) escaped the Austrian holocaust by emigrating to Britain from Nazi occupied Europe. Minna’s husband the Austrian sculptor Franz Pixner, was also touched by the momentous events of the twentieth century when he fought in the Spanish Civil War. ‘When my grandfather sustained life threatening injuries he was observed by Ernest Hemingway. Years later he ran into Hemingway again who told him that he’d partly based the protagonist Robert Jordan in ‘To whom the bell tolls’ on him.’

Rosenhek’s fascination with the scientific process was engendered by Kohn, who despite living in Santa Barbara regularly visited his European relatives. For his MD thesis Rosenhek studied the differential expression of tissue-type plasminogen activator in the aorta and the pulmonary arteries. ‘Above all the experience taught me that I wanted my future research to have a direct clinical impact,’ he says.

Graduating in 1998, Rosenhek went on to train in internal medicine and cardiology at the Medical University of Vienna, where he worked in a dedicated heart valve clinic. ‘At the time valve disease was in the doldrums, but the area has recently became much more prominent due to the increased incidence related to ageing populations and advances in echocardiography allowing earlier identification of disease. The field has now become particularly trendy due to the introduction of percutaneous therapies for valve disease,’ says Rosenhek.

For both aortic stenosis and mitral regurgitation Rosenhek has been a major contributor to the debate around optimal timing of interventions, supporting the view of ‘watchful waiting’ in asymptomatic mitral regurgitation, where asymptomatic patients are followed until they develop symptoms. To identify predictors of outcome Rosenhek prospectively used echocardiography to study a cohort of 128 patients with asymptomatic, severe aortic stenosis (NEJM 2000, 343: 652-654). The study identified calcification of the aortic valve and haemodynamic progression as risk factors for adverse outcomes, which became accepted criteria to refer patients early for surgery. For other patients, however, it was considered safe to wait until they developed symptoms. Submitting his first ever paper to the New England Journal of Medicine, says Rosenhek, involved an element of ‘youthful bravado’ which has paid off for the rest of his career.

Later he prospectively followed 116 asymptomatic patients with very severe aortic stenosis (defined by peak aortic jet velocities > or =5.0 m/s) and found that 96 events (including two cardiac deaths) occurred in a median follow-up of 41 months (Circulation 2010, 11:151-6). The study resulted in recommendations for early elective valve replacement in such patients.

In the setting of severe degenerative mitral regurgitation Rosenhek showed that asymptomatic patients can be safely followed until either symptoms occur or currently recommended cut-off values for LV size, LV function, or pulmonary hypertension are reached (Circulation 2006, 113:2238-44).
Rosenhek’s work contributed to the guidelines on valvular heart disease of the ESC and American College of Cardiology/ American Heart Association. ‘It is a nice feedback when you’re work influences clinical practice, ‘he says.

For the optimal implementation of ‘watchful waiting’ Rosenhek firmly believes that dedicated heart valve clinics need to be put in place. Together with Patrizio Lancellotti of EACVI, Rosenhek authored a position paper in the European Heart Journal (published online January 4) calling for more dedicated heart valve clinics to be established. ‘The bottom line is dedicated clinics provide higher quality health care that conforms more precisely to best practice guidelines,’ he says. Not only can patients be followed really closely and called back to the clinic on a regular basis, but clinicians get the opportunity to see large number of patients, develop structured teaching programmes and construct large data bases. ‘Furthermore input from a functioning heart team composed of valve and imaging specialists, cardiac surgeons, interventionalists and anaesthesiologists allows for a very balanced decision making.’

Indeed a UK study by John Chambers showed that the number of patients followed up according to best practice guidelines rose from 41 to 92% when heart valve clinics were introduced, and the total number of unwarranted echocardiographies fell significantly (British Journal Cardiol 2011, 18:231-232). Rosenhek’s plans for the WG on Valve Disease, include the production of more joint position papers. Since joining the ESC in 2002 Rosenhek has also served on  programme committees for the main ESC meeting and Euroecho meeting, and is also a member of the ESC Task Force on Medical Devices.

Rosenhek’s international work has undoubtedly been aided by his ability to speak English, French, German, Spanish and Italian all fluently. His hobbies include contemporary art, and reading literature in the original language. ‘When I travel I make a special point of visiting art galleries and speaking the local language if possible,’ he says.