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Cardiac MRI and CT are increasingly used in the diagnosis and management of patients with congenital heart disease as an imaging adjunct to echocardiography. The benefits and limitations of both modalities are highlighted, with a focus on the anatomical, functional and haemodynamic information that can be gained from the different modalities. Deciding on the imaging modality of choice must also take into account patient factors such as age, compliance, the type of congenital heart disease, and previous procedures. Future developments in CT and MRI are also discussed.

Echocardiographic assessment of patients with transposition of the great arteries and congenitally corrected transposition requires awareness of the morphology and commonly associated lesions. The pre-operative echocardiography should include a full segmental and sequential analysis. Post-operative assessment is not possible without awareness of the type of surgical procedure performed and consists of assessing surgical connections and residual lesions.

Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients’ outcomes.

As heart valve disease increases in prevalence in an ageing population, comorbidities make patients increasingly hard to assess. Specialist competencies are therefore increasingly important to deliver best practice in a specialist valve clinic and to make best advantage of advances in percutaneous and surgical interventions. However, patient care is not improved unless all disciplines have specialist valve competencies, and there is little guidance about the practical details of running a specialist valve clinic. In this issue of Echo Research and Practice, the British Heart Valve Society (BHVS) and the British Society of Echocardiography (BSE) introduce a series of articles to guide all disciplines in how to run a valve clinic.

Echocardiography is the key to the detection and initial assessment of valve disease. The examination helps differentiate severe from moderate disease if this is unclear from the echocardiogram, but is less useful than echocardiography for surveillance. However, the history is extremely important because symptoms are an indication for surgery in all types of valve disease. In aortic stenosis, the mortality rises soon after the onset of exertional breathlessness or chest tightness. Exercise testing is an extension of the history and may reveal symptoms in apparently asymptomatic patients. This article discusses the history, examination and exercise testing in patients either newly referred or under routine follow-up in a specialist valve clinic.

In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.

The prevalence of heart valve disease is increasing as the population ages. A series of studies have shown current clinical practice is sub-optimal. Some patients are referred for surgery at advanced stages of disease with impaired ventricular function or not even considered for surgery. Valve clinics seek to improve patient outcomes by providing an expert-led, patient-centred framework of care designed to provide an accurate diagnosis with active surveillance of valve pathology and timely referral for intervention at guideline directed trigger points. A range of different valve clinic models can be adopted depending on local expertise combining the skill set of cardiologist, physiologist/scientist and nurses. Essential components to all clinics include structured clinical review, echocardiography to identify disease aetiology and severity, patient education and access to both additional diagnostic testing and a multi-disciplinary meeting for complex case review. Recommendations for training in heart valve disease are being developed. There is a growing evidence base for heart valve clinics providing better care with increased adherence to guideline recommendations, more timely referral for surgery and better patient education than conventional care.

At its inception, transthoracic echocardiography (TTE) was employed as a basic screening tool for the diagnosis of heart valve disease and as a crude indicator of left ventricular function. Since then, echocardiography has developed into a highly valued non-invasive imaging technique capable of providing extremely complex data for the diagnosis of even the subtlest cardiac pathologies. Its role is now pivotal in the diagnosis and monitoring of heart disease. With the evolution of advanced practice and devolving care, ordinarily performed by senior doctors, to the cardiac physiology workforce in the UK, significant benefits in terms of timely patient care and cost savings are possible. However, there needs to be appropriate level of accountability. This accountability is achieved in the UK with statutory regulation of healthcare professionals and is a crucial element in the patient protection system, particularly for professions in patient facing roles. However, statutory regulation for staff practising echocardiography is not currently mandatory in the UK, despite the level of responsibility and influence on patient care. Regulators protect the public against the risk of poor practice by setting agreed standards of practice and competence and registering those who are competent to practice. Regulators take action if professionals on their register do not meet their standards. The current cardiac physiology workforce can be recognised as registered clinical scientists using equivalence process through the Academy for Healthcare Science, and this review aims to describe the process in detail.