BACKGROUND: Severe aortic stenosis (AS) is a common, serious valve disease in which no effective medical therapy is available and, if not treated by intervention, has a 5-year survival of only 40-60%. Despite the availability of guidelines supporting the effective use of surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) to treat the majority of these patients, adherence to these guidelines in clinical practice is still unsatisfactory. Several recent studies have emphasised the necessity for improved communication between multidisciplinary teams, with the aim to ensure that severe AS patients receive appropriate treatment. METHODS/DESIGN: IMPULSE is a prospective, multicentre, European registry designed to gather data over 12 months on the treatment decisions made by referring physicians for patients newly diagnosed with severe AS. Each patient has a follow-up of 3 months. The study will consist of two observational phases to assess the appropriateness and rate of referral based on current guidelines prior to and after an interventional phase aiming to determine whether a simple quality of care intervention improves patient management. DISCUSSION: Data will be analysed firstly, to determine the appropriateness of treatment decisions for the management of severe AS in current European clinical practice, and secondly, to evaluate the effectiveness of facilitated data relay from a designated echocardiography department nurse to the referring physician early after diagnosis in improving quality of care. Additionally, variables will be identified that are associated with inappropriate decision-making. Collectively, the aim will be to design a clinical pathway that will improve the timely management of patients with newly diagnosed severe AS.

Cardiology Department 1 University Clinic Mainz Mainz Germany

Clinic for Cardiology Angiology and Pneumology and Intensive Care Medicine Heart Center of the University Clinic Cologne Cologne Germany

Department of Cardiology and Angiology University of Kiel Kiel Germany

Department of Cardiology Bichat Hospital Paris France

Edwards Lifesciences Prague Czech Republic

Hospital de Sant Pau Cardiology Unit University of Barcelona Barcelona Spain

Institute for Pharmacology and Preventive Medicine Cloppenburg Germany

Queen Elizabeth Hospital and Institute of Cardiovascular Sciences University of Birmingham Birmingham UK

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Eveborn GW, Schirmer H, Heggelund G, Lunde P, Rasmussen K. The evolving epidemiology of valvular aortic stenosis. the Tromso study. Heart. 2013;99(6):396–400. doi: 10.1136/heartjnl-2012-302265. PubMed DOI

Osnabrugge RL, Mylotte D, Head SJ, Van Mieghem NM, Nkomo VT, LeReun CM, et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J Am Coll Cardiol. 2013;62(11):1002–12. doi: 10.1016/j.jacc.2013.05.015. PubMed DOI

Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Eur J Cardiothorac Surg. 2012;42(4):S1–44. doi: 10.1093/ejcts/ezs455. PubMed DOI

Ross J, Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38(1 Suppl):61–7. PubMed

Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10(1):1–25. doi: 10.1093/ejechocard/jen303. PubMed DOI

Evangelista A, Flachskampf FA, Erbel R, Antonini-Canterin F, Vlachopoulos C, Rocchi G, et al. Echocardiography in aortic diseases: EAE recommendations for clinical practice. Eur J Echocardiogr. 2010;11(8):645–58. doi: 10.1093/ejechocard/jeq056. PubMed DOI

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57–185. doi: 10.1016/j.jacc.2014.02.536. PubMed DOI

Brown JM, O'Brien SM, Wu C, Sikora JA, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009;137(1):82–90. doi: 10.1016/j.jtcvs.2008.08.015. PubMed DOI

Bakaeen FG, Chu D, Huh J, Carabello BA. Is an age of 80 years or greater an important predictor of short-term outcomes of isolated aortic valve replacement in veterans? Ann Thorac Surg. 2010;90(3):769–74. doi: 10.1016/j.athoracsur.2010.04.066. PubMed DOI

Florath I, Albert A, Boening A, Ennker IC, Ennker J. Aortic valve replacement in octogenarians: identification of high-risk patients. Eur J Cardiothorac Surg. 2010;37(6):1304–10. doi: 10.1016/j.ejcts.2009.12.025. PubMed DOI

Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Barwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003;24(13):1231–43. doi: 10.1016/S0195-668X(03)00201-X. PubMed DOI

Sharony R, Grossi EA, Saunders PC, Schwartz CF, Ciuffo GB, Baumann FG, et al. Aortic valve replacement in patients with impaired ventricular function. Ann Thorac Surg. 2003;75(6):1808–14. doi: 10.1016/S0003-4975(03)00117-6. PubMed DOI

Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607. doi: 10.1056/NEJMoa1008232. PubMed DOI

Buellesfeld L, Wenaweser P, Gerckens U, Mueller R, Sauren B, Latsios G, et al. Transcatheter aortic valve implantation: predictors of procedural success--the Siegburg-Bern experience. Eur Heart J. 2010;31(8):984–91. doi: 10.1093/eurheartj/ehp570. PubMed DOI

Piazza N, Grube E, Gerckens U, den Heijer P, Linke A, Luha O, et al. Procedural and 30-day outcomes following transcatheter aortic valve implantation using the third generation (18 Fr) corevalve revalving system: results from the multicentre, expanded evaluation registry 1-year following CE mark approval. Euro Intervention. 2008;4(2):242–9. PubMed

Thomas M, Schymik G, Walther T, Himbert D, Lefevre T, Treede H, et al. Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: A European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation. 2010;122(1):62–9. doi: 10.1161/CIRCULATIONAHA.109.907402. PubMed DOI

Chan RH, Shaw JL, Hauser TH, Markson LJ, Manning WJ. Guideline adherence for echocardiographic follow-Up in outpatients with at least moderate valvular disease. J Am Soc Echocardiogr. 2015;28(7):795–801. doi: 10.1016/j.echo.2015.03.001. PubMed DOI

Freed BH, Sugeng L, Furlong K, Mor-Avi V, Raman J, Jeevanandam V, et al. Reasons for nonadherence to guidelines for aortic valve replacement in patients with severe aortic stenosis and potential solutions. Am J Cardiol. 2010;105(9):1339–42. doi: 10.1016/j.amjcard.2009.12.056. PubMed DOI

Iung B, Messika-Zeitoun D, Cachier A, Delahaye F, Baron G, Tornos P, et al. Actual management of patients with asymptomatic aortic valve disease: how practice fits with guidelines. Am Heart J. 2007;153(4):696–703. doi: 10.1016/j.ahj.2005.12.031. PubMed DOI

Iung B, Cachier A, Baron G, Messika-Zeitoun D, Delahaye F, Tornos P, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J. 2005;26(24):2714–20. doi: 10.1093/eurheartj/ehi471. PubMed DOI

Rosenhek R, Iung B, Tornos P, Antunes MJ, Prendergast BD, Otto CM, et al. ESC working group on valvular heart disease position paper: assessing the risk of interventions in patients with valvular heart disease. Eur Heart J. 2012;33(7):822–8. doi: 10.1093/eurheartj/ehr061. PubMed DOI PMC

Chambers JB, Ray S, Prendergast B, Taggart D, Westaby S, Grothier L, et al. Specialist valve clinics: recommendations from the British heart valve society working group on improving quality in the delivery of care for patients with heart valve disease. Heart. 2013;99(23):1714–6. doi: 10.1136/heartjnl-2013-303754. PubMed DOI

Lancellotti P, Rosenhek R, Pibarot P, Iung B, Otto CM, Tornos P, et al. ESC working group on valvular heart disease position paper--heart valve clinics: organization, structure, and experiences. Eur Heart J. 2013;34(21):1597–606. doi: 10.1093/eurheartj/ehs443. PubMed DOI

Taggu W, Topham A, Hart L, Carr-White G, Sulke N, Patel NR, et al. A cardiac sonographer led follow up clinic for heart valve disease. Int J Cardiol. 2009;132(2):240–3. doi: 10.1016/j.ijcard.2007.11.076. PubMed DOI

Shojania KG, McDonald KM, Wachter RM, Owens DK. Closing The Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1—Series Overview and Methodology. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practices Center). AHRQ Publication No. 04-0051-1. Rockville, MD: Agency for Healthcare Research and Quality. PubMed

Walsh JM, McDonald KM, Shojania KG, Sundaram V, Nayak S, Lewis R, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44(7):646–57. doi: 10.1097/01.mlr.0000220260.30768.32. PubMed DOI

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