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CardioPulse ArticlesWelcome to the Acute Cardiovascular Care AssociationUPDATE programmes of the European Society of CardiologyArteriosclerosis, Thrombosis, and Vascular Biology JournalProfile: Montreal Cardiology Institute, CanadaTranscatheter Valve Treatment Pilot Registry: design and current status

DOI: http://dx.doi.org/10.1093/eurheartj/ehs244 2237-2245 First published online: 14 September 2012

Welcome to the Acute Cardiovascular Care Association

The ESC has established a new Association to help improve the management of patients needing acute cardiovascular care

The scope of the Working Group on Acute Cardiovascular Care has become much wider since its first creation, and we have all witnessed great progress in the diagnosis and management of acute cardiovascular conditions. Over these 12 years our focus has also evolved to a multi-disciplinary approach that brings together professionals from the majority of medical disciplines. As well as all of the cardiology sub-specialties, we have welcomed the excellent contribution of experts from emergency medicine, intensive care, anaesthesia, radiology, nursing, medical technology, paramedics, and many other healthcare professions.

In February 2011, we amended the Working Group's objective to reflect the new scope and to extend our remit beyond the walls of the ICCU. Our new mission, to improve the quality of care and outcome of patients with acute cardiovascular diseases, is intended to encompass the period between the pre-hospital phase all the way up to the end of the first week of hospitalization, leading to consider increased complexity in the management of cardiovascular disease, major advances in diagnosis and treatment strategies, and the contribution to patient outcomes made by professionals from many other healthcare disciplines.

It was agreed that this ambitious objective would be best achieved by forming a ‘unique scientific body’ to facilitate the integration of experts and sharing of techniques in the management of acute cardiovascular care across Europe.

The substantial portfolio of assets owned and developed by the Working Group over a number of years has served as a solid foundation to argue in favour of a new Association. These assets include a renowned Congress, a brand-new journal, a textbook on intensive and acute cardiac care, an established certification programme and—most importantly—an active membership approaching 1000 from over 70 countries.

The European Society of Cardiology favoured the creation of a new Acute Cardiovascular Care Association (ACCA) and ACCA was launched at the ESC general assembly, during the ESC Congress 2012 in Munich.

From now on, the ACCA will build on the efforts of the Working Group it replaces and will continue to offer state-of-the-art scientific and educational programmes for all professionals involved in acute cardiac care.

The creation of the ACCA should also be influential in guiding National Cardiac Societies towards a set of common standards for the delivery of the best treatments to patients admitted to intensive care units.

Acute cardiac care is typically delivered by a multiplicity of professionals and not only cardiologists. Although we expect the core of our membership to be drawn from healthcare professionals directly involved in acute cardiac care, we also extend a warm welcome to other groups including scientists and researchers, policy-makers, health managers, and members of allied societies. We encourage all persons interested in our sub-specialty to apply for membership and help us to steer the ACCA to become a respected and authoritative voice in the field of acute cardiac care.

There are numerous advantages to membership of the ACCA—check our web site www.escardio.org/ACCA and join us now!

Peter Clemmensen, President ACCA

View this table:

ACCA Board and structure

UPDATE programmes of the European Society of Cardiology

Drs Maarten L. Simoons and Felix Zijlstra summarize the highlights of the 2012 programme recently held in Rotterdam

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Maarten L. Simoons

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Felix Zijlstra

Cardiology is evolving rapidly. In the second half of the last century, cardiac surgery, interventional cardiology, and clinical electrophysiology developed, and many new drugs were introduced to the benefit of our patients. This development continues with, for example, percutaneous implantation of valves, new stents, improved ablation techniques for cardiac arrhythmia's and new anticoagulants. The rapid evolution is a challenge for cardiologists and related physicians since it requires continuous changes in the way cardiology is practiced at all levels, from private practice to hospital practice and practice in academic medical centres.

The European Society of Cardiology addresses this challenge through a strong focus on continuous education of cardiologists and related healthcare professionals. The UPDATE programmes of the ESC are part of this effort, with biannual courses in Davos and Rome and an annual course in Rotterdam. In contrast to the ESC congresses, with many parallel sessions, these update programmes offer a broad overview of recent developments and their implications in a single auditorium. Most recently, in June 2012, some 250 participants from many countries in Europe, South America, and Asia attended and enjoyed ‘Cardiology and Vascular Medicine’ in Rotterdam. A few highlights of this programme are summarized in this report. After 3 days, the programme was concluded with a personal overview ‘From Eisenhower's heart attack to modern cardiology’ by the editor of this journal, Thomas Lüscher from Zürich.

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Acute coronary syndromes

Atherosclerosis with plaque rupture or other disruptions of the endothelium are the main pathophysiological processes in acute coronary syndrome (ACS). However, the underlying inflammatory process in the vascular wall is poorly understood (Filippo Crea, Rome). Statins may reduce such inflammation and some trials are on-going to assess the value of specific anti-inflammatory agents such as methotrexate in ACS. The most recent ESC guidelines advise treatment of ACS with new anti-platelet drugs (ticagrelor, prasugrel) and with revascularization by PCI or bypass surgery in most patients (Jean Pierre Bassand, Besançon) presenting with or without ST-segment elevation (Rob de Winter, Amsterdam). New anticoagulants (Factor Xa inhibitors apixaban and rivaroxaban and the thrombin receptor blocker voraxapar) have been tested in patients after ACS, with limited success. It is questionable whether triple therapy with aspirin, clopidogrel, and these new agents will have any advantage over double therapy with aspirin and ticagrelor or prasugrel (Maarten Simoons, Rotterdam). Stents continue to improve and with current stents the risk of the dreaded acute stent thrombosis is very low, both in patients with chronic disease and ACS (Stephan Windecker, Bern). Nevertheless, in patients with complex three-vessel coronary anatomy, bypass surgery remains the first choice for revascularization.

Atrial fibrillation and other arrhythmias

Many episodes of AF are asymptomatic, and the incidence of, particularly, paroxysmal AF strongly relates to the type of monitoring employed. The recent ESC guidelines recommend early rhythm control in patients with AF and confirm that ablation may be offered as first-line therapy in some patients (Irene Savelieva, London). However, it should be appreciated that some patients with AF also have other arrhythmias requiring ablation therapy (Tim Simmers, Breda). Anticoagulant therapy is crucial in patients with a CHA2DS2VASc score ≥1. The new anticoagulants dabigatran, apixaban, and rivaroxaban at appropriate doses offer a better safety profile for similar efficacy than coumadin and are the preferred mode of treatment (Felicita Andreotti, Rome)

Valvular heart disease

Functional assessment of the severity of valvular heart disease remains a challenge in some patients and often relies on a combination of different structural and functional parameters, as assessed by echocardiography (Renée van den Brink, Amsterdam). Surgical repair or replacement of a diseased aortic or mitral valve remains the first choice, although percutaneous replacement of the aortic valve is rapidly improving and may be offered to elderly patients with a high surgical risk (Alec Vahanian, Paris). Large studies are on-going to better distinguish whether surgical or percutaneous treatment is the preferred option for specific patients. New, ‘minimal invasive’ surgical techniques are applied successfully in valve surgery. Percutaneous treatment of mitral valve incompetence is under development using different devices, with variable results (Jan Van der Heyden, Nieuwegein).

Imaging of the heart and vessels

Modern MRI, CT, and PET-CT techniques offer excellent anatomic and functional evaluation of the structure of the heart, the myocardium, and coronary arteries. This opens the way for early detection of disease, or confirmation of the absence of disease, and better guidance for the choice of invasive therapy (Johani Knuuti, Turku; Jeroen Bax, Leiden).

Heart failure

Exercise training improves the quality of life, exercise capacity, and cardiac function, whilst blunting cardiac remodelling in patients with chronic (systolic) heart failure. Training early after MI appears safe and effective in attenuating cardiac remodelling and improving cardiac function. However, the optimal type, start, duration, and intensity of exercise training early after MI remains to be established (Dirk Duncker, Rotterdam).

ICD therapy in patients with severe heart failure effectively improves life expectancy, but it may be hampered by appropriate and inappropriate shocks. In such patients, ablation of ventricular and supra-ventricular arrhythmias should be considered to reduce the shocks (Natasja de Groot, Rotterdam).

Management of acute heart failure is predominantly based on clinical experience, with relatively little evidence from larger clinical trials. Nevertheless, the ESC recently updated guidelines for acute heart failure, which recommend a structured approach to address ventilation, arrhythmias, blood pressure and tissue perfusion, as well as underlying ACSs or mechanical dysfunction of the heart (Christian Vrints, Antwerp). In selected patients' mechanical support with an intra-aortic balloon pump, cardiac assist device or extra corporal membrane oxygenator (ECMO) should be considered.

Case presentations

Every section of the programme was rounded off by an interactive discussion of cases introduced by staff members of the Thoraxcenter. These case presentations were judged to be the ‘icing on the cake’ according to the evaluation by the participants. Such interactive sessions should be part of many more CME programmes.

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After attending ESC-UPDATE programmes in Davos, Dubrovnik, Rome, and Rotterdam, it is evident that such programmes have much to offer to practising cardiologists. Continuous education is a professional requirement. It is mandatory in many countries in Europe, and a moral obligation for all of us.

CME may be obtained in the direct environment that cardiologists practice, in their own country, or internationally. We suggest that optimal CME should be followed at all three levels, one-third locally, one-third at the national level, and one-third at international programmes such as the ESC Congress, the ESC sub-speciality congresses, or the ESC UPDATE programmes.

Thoraxcenter, Erasmus MC, Rotterdam

Arteriosclerosis, Thrombosis, and Vascular Biology Journal

Launched to expand the American Heart Association's portfolio of journals, ATVB has developed its own niche in the cardiovascular arena

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Back in the 1980s the American Heart Association (AHA) began to launch a family of journals on specialized topics. It would enable the AHA to publish research articles that exceeded the capacity of its flagship journal Circulation.

Today many journals have spinoff publications, but the AHA was ahead of its time. It had realized that one journal could not cover all of the diverse areas related to cardiovascular disease.

Arteriosclerosis was launched in 1981. In 1991, the name was changed to Arteriosclerosis and Thrombosis to enable the AHA's thrombosis experts to combine forces with a related field. The journal's name became Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB) in 1995 to acknowledge the fact that there were many basic science aspects related to the health and disease status of the vascular system that did not fall under the label arteriosclerosis. It also recognized that ‘having knowledge about what is normal in a healthy artery helps you understand the disease process better’, says editor-in-chief Professor Edward A. Fisher, Leon H. Charney Professor of Cardiovascular Medicine, director of the Marc and Ruti Bell Vascular Biology Program, New York University School of Medicine, and from 2010 to 2011 Eastman Professor at the University of Oxford, UK. The broader scope enables the journal to recruit high-quality papers from a larger pool of scientists and to be more selective.

ATVB has a close relationship with the AHA's Council on Arteriosclerosis, Thrombosis and Vascular Biology. All AHA journals publish a mixture of basic science and clinical research papers but the proportion varies. The bulk of ATVB's papers are basic science, but they also welcome original research in the areas of cardiovascular genetics and clinical epidemiology. Most of the readers are basic scientists, with a reasonable sprinkling of physician scientists as well. They include academic cardiologists, vascular biologists, physiologists, biochemists, pharmacologists, and haematologists.

ATVB is published monthly and has a circulation of over 15 400. With an impact factor of 7.235 it ranks third among 60 journals in the peripheral vascular disease category and sixth among 61 journals in the haematology category. The manuscript acceptance rate is 18%. The time from submission to first decision is 3.2 weeks and from acceptance to publication is 10–14 days (electronic) and 6–8 weeks (print).

The editor in chief also functions as an associate editor, of which there are six in the USA. There is one editor from Europe , five associate editors from Europe, and one editor from Asia. The Asia editor handles all papers from that region, whereas in Europe and the USA editors self-assign manuscripts based on their areas of expertise. They then handle the review process and make a final decision. Papers for which the decision about whether or not to publish is not clear cut are discussed during a weekly teleconference.

By contributing equally the editor in chief decreases the number of manuscripts each editor has to handle and has a working knowledge of ATVB's editorial process. ‘You're also keeping up with your own field by managing manuscripts since you're selecting things in your area of expertise’, says Fisher.

Fisher took over from Dr Mark B. Taubman, who had been appointed dean of the School of Medicine and Dentistry and university vice president for health sciences at the University of Rochester Medical Center in New York and no longer had time to lead a major journal. Taubman had finished 4 years of a 5-year term and Fisher agreed to take the post for the final year (2011–12) while a successor was recruited. He declined an offer to stay for 1 year plus potentially two 5-year terms (11 years total) having just turned 60 and anticipating retirement at 70. ‘I decided that for the last 10 years I wanted to direct all my energies to the research programme that I have’, he says.

Taubman organized the existing editorial team and Fisher was one of his associate editors. Policy decisions were developed by consensus and Fisher will continue to implement the current approach. ATVB aims to continue attracting the best science by maintaining quality control over what it publishes. When researchers see good papers in the journal, it should prompt them to submit their own manuscripts. The AHA has been discussing the future of print journals and the possibility of online only journals but ATVB has decided that it wants to continue the print edition for the foreseeable future.

The journal has been enjoying success with a series of thematic reviews in which a prominent expert is asked to commission and edit four to six articles that are published in the same issue. But the number of articles results in a time lag so in the future ATVB will commission single brief reviews on current hot topics that do not need to be bundled with other papers. Fisher says: ‘We want to be able to move more quickly on hot topics and help people interpret the current trends’.

Jennifer Taylor, MPhil

Profile: Montreal Cardiology Institute, Canada

Professor Jean-Claude Tardif, director of research at the Montreal Heart Institute, talks about growth, collaboration, and the impact of good translational research, to Emma Wilkinson, MA

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Dr Jean-Claude Tardif

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Montreal Cardiology Institute

The list of global ‘firsts’ listed on the Montreal Cardiology Institute's website does a good job of highlighting the international importance of the work done at Canada's premier cardiology centre. Just a year after the Institute first opened in 1954, with just 42 beds, three cardiologists, and two surgeons, it saw the first intramyocardial implantation of the internal mammary artery, a step preceding the development of aortocoronary bypass. Since then, specialists at the Institute were the first to publish a description of occluded grafts after aortocoronary bypass leading to key changes in medical treatments. And most recently, its cardiologists were the first to carry out a CROSSER heart catheterization procedure on a child with a completely occluded coronary artery.

Now, with 153 beds and 195 doctors on staff, the Institute treats many thousands of patients every year. The sheer scale of the Institute's work is perhaps unrecognizable from that first attempt to provide more seamless care by bring cardiology services all together under one roof. Yet Prof Jean-Claude Tardif points out that some of the most impressive growth in recent years has in fact been in its Research Centre. As its director he leads a team of around 650 scientists and staff who publish in excess of 300 journal articles a year.

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Research Centre, Montreal Cardiology Institute

‘There has been rapid and structured growth in the past 10–15 years in our research’, he says. ‘There has been a large amount of money available in Canada for the development of research infrastructure and we were fortunate in winning a lot of these competitions allowing us to invest around $200 million and really transforming what we are able to do’.

From such a wealth of research undertaken at the Institute, it is extremely difficult, he says to pick the bits that stand out. But we always aim at ‘really changing how we treat patients’ he points out. ‘We have been very active in atherosclerosis, particularly in HDL therapies and also a leader in the development of novel imaging modalities. On the basic science front, work on electrophysiology has helped the worldwide understanding of atrial fibrillation. In other studies we have shown benefit of HDL therapies on previously unsuspected targets and we are now translating this into new clinical studies’.

Although it is tempting to discuss the clinical and research side of the Institute as two different centres under the same umbrella, in reality, there is a great deal of crossover and he is very proud of the ‘unique and intense’ interaction between the two. Even within the research centre, there is a ‘really nice balance’ between the ‘basic, translational and clinical sciences’ which he believes greatly accelerates the path of getting new innovations to patients.

‘Our work is really multifaceted – everything from prevention to invasive cardiology. We not only have a classical hospital with 47 cardiologists where we carry out cardiac interventions and surgeries on children and adults but we have 650 people working in the research centre all focusing on the heart. We are a big group and we get referrals in the region of Montreal and across Quebec and in some cases from right across Canada’.

It is impossible to talk about the Montreal Heart Institute without mentioning the ÉPIC (Étude Pilote de l'Institut de Cardiologie) Centre for Preventive Medicine and Physical Activity. The largest of its kind in Canada and most likely the world, it has 4500 participants in primary and secondary cardiovascular disease prevention. ‘People train and get expertise in lifestyle initiatives, exercise and cooking classes', says Prof Tardif. ‘We also have a large group that does interventions in the working environment and have led major campaigns around smoking cessation, exercise, and better eating habits. We are extremely proud of this and I don't think a lot of other hospitals do this on such an enormous scale—trying to change the lifestyle habits of the population’.

After many years of good fortune in terms of research investment, there is always a slight worry that in the current economic climate, the Institute will not be able to keep growing and achieving at the level it has. But with the Canadian government being extremely supportive of the life sciences and the generosity of a number of donors to the Montreal Heart Institute Foundation, Prof Tardif is optimistic.

With the very recent news that Roche has selected the Institute for its global research hub in cardio metabolic disease, he has every reason to be hopeful that the next decade will be as fruitful as the last.

‘We are very proud of our relationship with the biotech and pharma industries. Canada and specifically Quebec have put in place a lot of initiatives to make us appealing to the pharmaceutical industry, which is extremely important. Montreal is a major hub for biotech and health-related sciences and it is vital that we maintain it’, he says.

Looking to the future, he has very clear ideas about the Institute's research goals. ‘We are very focused on personalized healthcare and we have invested massively in this area’. He continues: ‘What we hope to see in the next few years is the true implementation of personalized health care in cardiovascular medicine. We really want this area of research to radically change the way we diagnose and treat patients and closely related to this is the discovery and development of biomarkers. Finding those biomarkers that suggest people are at risk and working out how we should react to them—I think this personalization of healthcare is going to have a really big impact’.

As well as working as a cardiologist, his personal research is directed at therapies to reduce the progression of atherosclerosis so it is not surprising that he believes this too will see important results in the coming years. ‘We really want to have a major impact on atherosclerosis and cardiovascular disease because of the impact this has on a population scale on morbidity and mortality. We are doing a lot of work on HDL therapies and therapies that target inflammation. I'm not saying we're going to cure cardiovascular disease just yet but we think that we are going to contribute to significant advances’.

Emma Wilkinson, MA

Transcatheter Valve Treatment Pilot Registry: design and current status

The essential details of this trans-national European Registry are discussed by Drs Di Mario, Maggioni, and Tavazzi

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Carlo Di MarioAldo MaggioniLuigi Tavazzi

Introduction

Transcatheter valve treatment is the most recent innovation in the field of interventional cardiology. It was a brave choice for the Oversight Committee of the EURObservational Research Programme (EORP) to select this topic for a Sentinel Registry, potentially competing with company-sponsored large registries, national registries, and large randomized trials.

The unique feature of the transcatheter valve registry

The TransCatheter Valve Registry (TCVR) mainly contains electronically transferred patient data from 6 out of the 13 countries selected for the pilot phase. The advantage is obvious: data filed on-line and required for reimbursement are more reliable because they are subject to audit and scrutiny. It looks an easy task but only if the European registry is able to put together different databases and promote the use of common definitions and standards. It was a lucky coincidence that, at the time of planning this registry, the VARC (Valve Academic Research Consortium) definitions were published and there was interest to adapt the national registries to this new accepted standard.1 In the two countries where the national registries were too incomplete and in the other five having no national registries, a web-based database (https://www.euroheartsurvey.org/) was offered, to allow centres to enter their data directly.

Aims of the registry

The aim of the TCVR is the assessment of the frequency of use, indications, periprocedural device success, 1-month safety, and 1-year efficacy of transcatheter valve treatment in the various European countries. The inclusion of inoperable or high surgical risk patients implies that a high mortality is expected because of comorbidities or advanced heart failure, even if the device achieves complete success in restoring valve function. VARC proposes to use all-cause mortality as a primary clinical endpoint, but strongly recommends careful investigation of the cause of death, with individual adjudication by a clinical events committee and particular detailed attention to deaths caused by device malfunction or direct complications. For the purpose of analysis, death of unknown aetiology will be bundled with cardiovascular death. Stroke, pacemaker implantation, renal failure, and vascular access complications will be carefully investigated using CT, MRI, and specialist neurology input. Hopefully, this will resolve the questions created by the large discrepancy in incidence of stroke and pacemaker implantation observed in some industry-sponsored trials.

Periprocedural success for TAVI is defined as the combined achievement of a successful vascular access, delivery, and deployment of the device and retrieval of the delivery system, with a valve implanted in the proper anatomical location achieving an aortic valve area >1.2 cm2, mean aortic valve gradient <20 mmHg, or peak velocity <3 m/s, without moderate or severe prosthetic aortic valve regurgitation. For MitraClip implantation, success is defined as the delivery of one or more MitraClips correctly grasping both mitral leaflets and achieving reduction of the mitral regurgitation of one grade or more with a mitral valve area still >1.5 cm2.

Primary endpoint is 1-month safety defined as survival without major stroke, life-threatening bleeding, Grade 3 acute kidney injury, periprocedural MI, or need for a repeat procedure for valve-related dysfunction (surgical or transcatheter). A prolonged follow-up is required for the secondary but relevant endpoint of 12-month efficacy, defined for TAVI as survival with no hospitalizations for symptoms of valve-related dysfunction or cardiac decompensation or recurrence of aortic stenosis or moderate to severe prosthetic aortic valve regurgitation. For MitraClip implantation, the definition is modified as survival with no hospitalizations for symptoms of valve-related dysfunction, cardiac decompensation, or recurrence of mitral regurgitation of the same grade as pre-procedure.

A secondary substudy addresses quality of life at 1 year. If a sufficiently large population of patients is studied, the registry can be used in analogy with previous work done in cardiac surgery to determine and validate a European Valve SCORE, able to identify the weight of various clinical parameters from demographics to comorbidities as well as the pathology that valve characteristics have in determining mortality. Matched patients treated using different access sites, type of valve/device, type of imaging modality for planning and execution, with variable centre and operator experience will be compared.

State of the pilot registry in March 2012

Enrolment started in May 2011 and most countries have solved the legal (consent, elimination of demographic data making the patient identifiable, approval from the competent National Health Authorities) and IT problems connected with data transfer. On 28 February 2012, more than 4000 patients were either directly entered into the electronic database in Italy, Poland, Germany, and Belgium or transferred from the French, Czech, Spanish, Dutch, and British registry. The aim is to process the data with appropriate cleaning and analysis in time for presentation at the ESC European Congress in Munich. For the MitraClip, 125 patients have been enrolled in 14 centres.

Preliminary results for TAVI indicate that there is an equal distribution of the two sexes, with the majority of patients aged 81–90 years. Almost 30% of patients are younger than 80 years and have major comorbidities explaining why surgery was avoided: Chronic Obstructive Pulmonary Disease (COPD), porcelain aorta, chest deformity, dialysis or previous surgery (23% of cases). The logistic EuroScore is much higher in the younger group, a paradox when you consider that age adds points to the EuroScore. The average was 22 for patients aged 80 years old or younger and 15 for patients older than 80 years.

There is a slight prevalence of implanted Edward valves with 19% trans-apical, balanced by 8% trans-subclavian Corevalves and still very few valves implanted by a direct aortic approach. All other implants were transfemoral, which may explain a moderately high use of local anaesthesia only, 38%.

The overall results in terms of 30-day mortality are very comparable with the mortality observed in SOURCE2 or in the Cohort B of the PARTNER study3 as expected, since the patients enrolled were by definition inoperable or at very high risk. MitraClip patients were younger (76 years), with greater than Grade 2 functional mitral regurgitation as the most frequent indication.

Future perspectives

If successful, the Sentinel registry will be prolonged and enlarged to include all European countries, becoming a permanent long-term source of reliable independent data to monitor the changes in indications and results of this new technology. If successful, the methodology followed in this registry based on data transfer of all procedures offers an alternative model of help than individual entry to plan future diagnostic or therapeutic European registries.

Carlo Di Mario

Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK

Aldo Maggioni

European Heart House, Sophia Antipolis, France

Luigi Tavazzi on behalf of the Executive and Steering Committee

Maria Cecilia Hospital, ES Health Science DFoundation, Cotignola, Italy

Executive and Steering Committees TCVR: Helene Eltchaninoff, France, Giampaolo Ussia, Italy, Peter Kala, Czech Republic, Erwin Schroeder, Belgium, M. Claeys, Belgium, E. Joergensen, Denmark, P. Wenaweser, Switzerland, Georg Nickenig, Germany, Roberto Corti, Switzerland, Bernard Prendergast, UK, J. Nilsson, Sweden, Javier Goicolea, Spain, Eduardo Alegria-Barrero, Spain, Peter den Heijer, Netherlands, Reter Ludman, UK, Marian Zembala, Poland, Neil Moat, UK, Bernard Iung, France, Gerhard Schuler, Germany, Jose Zamorano, Spain, Ottavio Alfieri, Italy, Olaf Franzen, Denmark, Susanna Price, UK, Gerald Gracia, France

References