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Waldron C, Mori M, Krane M, Reinhardt SW, Ahmad Y, Kaple R, Forrest JK, Geirsson A. Implementing Formal Mitral Heart Team Improves Multidisciplinary Evaluation Rate and Survival of Patients With Severe Primary Mitral Regurgitation. J Am Heart Assoc 2024; 13:e033324. [PMID: 38390804 PMCID: PMC11179864 DOI: 10.1161/jaha.123.033324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/17/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Multidisciplinary heart team (HT) evaluation is recommended for patients with severe primary mitral regurgitation to optimize treatment decisions. However, its impact on patient outcomes remains unknown. We evaluated the impact of implementing mitral HT on patient survival. METHODS AND RESULTS We conducted a retrospective cohort study of patients with new diagnoses of severe primary mitral regurgitation in a large healthcare network echocardiogram database between 2016 and 2020. We compared the incidence of multidisciplinary evaluation by structural cardiology and cardiac surgery services and 2-year survival before and after mitral HT implementation. The 1:1 propensity-score matching between pre- and post-mitral HT used Society of Thoracic Surgeons Predicted Risk of Mortality for mitral repair, age, sex, race, heart failure symptoms, inpatient setting, history of MI, and dementia as covariates. Logistic regression identified variables associated with the likelihood of undergoing multidisciplinary evaluation. Among 70 510 echocardiograms performed, 391 patients had severe primary mitral regurgitation (median age, 77 years; 46% women). Multidisciplinary evaluation increased from 29% to 89% (P<0.001), and intervention increased from 24% to 75% following mitral HT implementation (P<0.001). Among 180 propensity-score matched patients, mortality was lower post-mitral HT at 2 years (19% versus 32%, P=0.04). The multivariable model showed that mitral HT implementation and heart failure symptoms were associated with higher odds of undergoing multidisciplinary evaluation (OR [odds ratio], 18.7 and 2.72, respectively), whereas female sex and older age were associated with lower odds (OR, 0.39 and 0.93, respectively). CONCLUSIONS Implementation of mitral HT was associated with drastic improvement in multidisciplinary evaluation for patients with severe primary mitral regurgitation. This coincided with higher proportions of patients undergoing mechanical correction of MR and improved overall patient survival.
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Affiliation(s)
- Christina Waldron
- Division of Cardiac SurgeryYale University School of MedicineNew HavenCTUSA
| | - Makoto Mori
- Division of Cardiac SurgeryYale University School of MedicineNew HavenCTUSA
- Center for Outcomes Research and Evaluation, Yale New Haven HospitalNew HavenCTUSA
| | - Markus Krane
- Division of Cardiac SurgeryYale University School of MedicineNew HavenCTUSA
- Department of Cardiovascular SurgeryInstitute Insure, German Heart Center MunichTechnical University of MunichMunichGermany
| | - Samuel W. Reinhardt
- Division of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Yousif Ahmad
- Division of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Ryan Kaple
- Division of Cardiovascular MedicineHackensack University Medical CenterHackensackNJUSA
| | - John K. Forrest
- Division of Cardiovascular MedicineYale University School of MedicineNew HavenCTUSA
| | - Arnar Geirsson
- Division of Cardiac SurgeryYale University School of MedicineNew HavenCTUSA
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. J Am Coll Cardiol 2023; 82:1131-1174. [PMID: 37516946 DOI: 10.1016/j.jacc.2023.03.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2023; 16:e00121. [PMID: 37499042 DOI: 10.1161/hcq.0000000000000121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
| | | | | | | | | | | | | | - Sandeep R Das
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | | | - Binita Shah
- Society for Cardiovascular Angiography and Interventions representative
| | - Nadia R Sutton
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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Ganhewa M, Lau A, Lay A, Lee MJ, Liang W, Li E, Li X, Khoo LY, Lee SM, Mariño R, Cirillo N. Harnessing the power of collective intelligence in dentistry: a pilot study in Victoria, Australia. BMC Oral Health 2023; 23:405. [PMID: 37340358 DOI: 10.1186/s12903-023-03091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/31/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND In many dental settings, diagnosis and treatment planning is the responsibility of a single clinician, and this process is inevitably influenced by the clinician's own heuristics and biases. Our aim was to test whether collective intelligence increases the accuracy of individual diagnoses and treatment plans, and whether such systems have potential to improve patient outcomes in a dental setting. METHODS This pilot project was carried out to assess the feasibility of the protocol and appropriateness of the study design. We used a questionnaire survey and pre-post study design in which dental practitioners were involved in the diagnosis and treatment planning of two simulated cases. Participants were provided the opportunity to amend their original diagnosis/treatment decisions after viewing a consensus report made to simulate a collaborative setting. RESULTS Around half (55%, n = 17) of the respondents worked in group private practices, however most practitioners (74%, n = 23) did not collaborate when planning treatment. Overall, the average practitioners' self-confidence score in managing different dental disciplines was 7.22 (s.d. 2.20) on a 1-10 scale. Practitioners tended to change their mind after viewing the consensus response, particularly for the complex case compared to the simple case (61.5% vs 38.5%, respectively). Practitioners' confidence ratings were also significantly higher (p < 0.05) after viewing the consensus for complex case. CONCLUSION Our pilot study shows that collective intelligence in the form of peers' opinion can lead to modifications in diagnosis and treatment planning by dentists. Our results lay the foundations for larger scale investigations on whether peer collaboration can improve diagnostic accuracy, treatment planning and, ultimately, oral health outcomes.
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Affiliation(s)
| | - Alison Lau
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Angela Lay
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Min Jae Lee
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Weiyu Liang
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Emmy Li
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Xue Li
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Lee Yen Khoo
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Su Min Lee
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia
| | - Rodrigo Mariño
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia.
- Center for Research in Epidemiology, Economics and Oral Public Health (CIEESPO), Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile.
| | - Nicola Cirillo
- Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Carlton, VIC, 3053, Australia.
- School of Dentistry, University of Jordan, Amman, 11942, Jordan.
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Metkus TS, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Burke JA, Fordyce CB, Guo J, Katz JN, Keeley EC, Menon V, Miller PE, O'Brien CG, Sinha SS, So D, Ternus BW, Vadhar S, van Diepen S, Morrow DA. Presentation and Outcomes of Patients With Preoperative Critical Illness Undergoing Cardiac Surgery. JACC. ADVANCES 2023; 2:100260. [PMID: 38357248 PMCID: PMC10865183 DOI: 10.1016/j.jacadv.2023.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Little is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. OBJECTIVES The purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. METHODS We analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. RESULTS Among 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. CONCLUSIONS Nearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.
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Affiliation(s)
- Thomas S. Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York City, New York, USA
| | - Vivian M. Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A. Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - James A. Burke
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Christopher B. Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G. O'Brien
- Division of Cardiology, Department of Medicine, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bradley W. Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Sagar Vadhar
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A. Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Ramos-López N, Ferrera C, Luque T, Enríquez-Vázquez D, Mahía-Casado P, Galván-Herráez L, Pedrajas JM, Salinas P, Fraile PZ, Islas F, Real C, Mejía-Rentería H, Jiménez-Quevedo P, Gonzalo N, Nuñez-Gil I, Nombela-Franco L, Tirado G, Macaya F, Escaned J, Hernández AMM, Bustamante J, Serrano MP, García EB, Pozzi MAO, Higueras J, Agustín AD, Viana-Tejedor A, Fernández-Ortiz A. Impact of a pulmonary embolism response team initiative on hospital mortality of patients with bilateral pulmonary embolism. Med Clin (Barc) 2023:S0025-7753(23)00017-9. [PMID: 36801109 DOI: 10.1016/j.medcli.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) response teams (PERT) for the management of high-risk PE (HR-PE) and intermediate-high risk PE (IHR-PE) are encouraged in PE guidelines. We aimed to assess the impact of a PERT initiative on mortality in these groups of patients, compared with standard care. METHODS We conducted a prospective, single-center registry, including consecutive patients with HR-PE and IHR-PE with PERT activation from February-2018 to December-2020 (PERT group, n=78 patients) and compared it with an historic cohort of patients admitted to our hospital in a previous 2-year period (2014-2016), managed with standard of care (SC-group, n=108 patients). RESULTS Patients in the PERT group were younger and less comorbid. The risk profile at admission and the percentage of HR-PE was similar in both cohorts (13% in SC-group and 14% in PERT-group, p=0.82). Reperfusion therapy was more frequently indicated in PERT-group (24.4% vs 10.2%, p=0.01), with no differences in fibrinolysis treatment, while catheter-directed therapy (CDT) was more frequent in PERT group (16.7% vs 1.9%, p<0.001). Reperfusion and CDT were associated with lower in-hospital mortality (2.9% vs 15.1%, p=0.001 for reperfusion and 1.5% vs 16.5%, p=0.001 for CDT). The primary outcome, 12-month mortality, was lower in the PERT-group (9% vs 22.2%, p=0.02), There were no differences in 30-day readmissions. In multivariate analysis PERT activation was associated with lower mortality at 12 months (HR 0.25, 95% confidence interval 0.09-0.7, p=0.008). CONCLUSION A PERT initiative in patients with HR-PE and IHR-PE was associated with a significant reduction in 12-month mortality compared with standard of care, and also with an increase in the use of reperfusion, especially catheter-directed therapies.
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Affiliation(s)
- Noemi Ramos-López
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Carlos Ferrera
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Tania Luque
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | | | - José María Pedrajas
- Internal Medicine Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Pablo Salinas
- Cardiovascular Institute, Hospital Universitario Clínico San Carlos, Madrid, Spain.
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Hoefsmit PC, Schretlen S, Does RJMM, Verouden NJ, Zandbergen HR. Quality and process improvement of the multidisciplinary Heart Team meeting using Lean Six Sigma. BMJ Open Qual 2023; 12:bmjoq-2022-002050. [PMID: 36707122 PMCID: PMC9884867 DOI: 10.1136/bmjoq-2022-002050] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/11/2023] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The Heart Team is a multidisciplinary meeting for shared decision-making in cardiology and cardiothoracic surgery. A quality improvement project to optimise the Heart Team was initiated after the merger of the cardiac centres of Amsterdam University Medical Centre. METHODS Lean Six Sigma was applied with the purpose of improving efficiency and quality of care. Qualitative and quantitative analyses supported the multidisciplinary team during quality improvement sessions. Lean Six Sigma tools included process mapping, gemba walks, root cause analysis, line balancing, first time right, standardised work and poka-yoke. INTERVENTIONS Seven areas of improvement were introduced. Key elements were the improvement of the patient referral process, introduction of a structured agenda, task division and balanced planning of patients, better exchange of information, improved availability of diagnostics and supportive tools and information technology. Work agreements were introduced to support a positive work culture and mutual respect. RESULTS Lean Six Sigma designed an optimised Heart Team to improve efficiency by better resource utilisation, first time right decision-making, patient selection, complete and better access to information and elimination of waste. It leads to higher quality of decision-making by involving physicians in a more structured preparation, attendance of an imaging cardiologist, meeting duration within limits, installation of standard operating procedures, increased involvement of the referring cardiologists and a better engaged team. CONCLUSIONS Heart Teams are essential to make evidence-based, patient-centred treatment plans for optimal patient outcomes. However, clinical practice and experience showed that it is challenging to have an efficient and effective discussion with complete patient information and to bring together healthcare professionals. The application of Lean Six Sigma resulted in an optimised Heart Team and created a best practice design for patient-centred, evidence-based decision-making. After implementation and process stability, a postintervention analysis could clarify long-term success and sustainability.
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Affiliation(s)
- Paulien C Hoefsmit
- Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, Netherlands .,Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Stijn Schretlen
- Integrated Health Solutions, Medtronic Europe, Eindhoven, Netherlands
| | - Ronald J M M Does
- Business Analytics, Amsterdam Business School, University of Amsterdam, Amsterdam, Netherlands
| | - Niels J Verouden
- Cardiology, Amsterdam UMC, Amsterdam, Netherlands,Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - H Reinier Zandbergen
- Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, Netherlands,Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
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Ma H, Lin S, Li X, Wang Y, Xu B, Zheng Z. Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases. BMJ Open 2022; 12:e064761. [PMID: 36456006 PMCID: PMC9716884 DOI: 10.1136/bmjopen-2022-064761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD). METHODS AND ANALYSIS Eighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry. TRIAL REGISTRATION NUMBER NCT05039567.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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11
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Huang YX, Xu ZM, Zhao L, Cao Y, Chen Y, Qiu YG, Liu YM, Zhang PY, He JC, Li TC. Long-term outcomes of high-risk percutaneous coronary interventions under extracorporeal membrane oxygenation support: An observational study. World J Clin Cases 2022; 10:5266-5274. [PMID: 35812664 PMCID: PMC9210891 DOI: 10.12998/wjcc.v10.i16.5266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/30/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) offers hemodynamic support for patients undergoing high-risk percutaneous coronary interventions (PCIs). However, long-term outcomes associated with VA-ECMO have not previously been studied.
AIM To explore long-term outcomes in high-risk cases undergoing PCI supported by VA-ECMO.
METHODS In the present observational cohort study, 61 patients who received VA-ECMO-supported high-risk PCI between April 2012 and January 2020 at the Sixth Medical Center of Chinese People’s Liberation Army General Hospital were enrolled. The endpoint characteristics such as all-cause mortality, repeated cardiovascular diseases, and cardiac death were examined.
RESULTS Among 61 patients, three failed stent implantation due to chronic total occlusions with severely calcified lesions. One patient showed VA-ECMO intolerance because of high left ventricular afterload. PCI was successfully performed in 57 patients (93.4%). The in-hospital mortality was 23.0%, and the overall survival was 45.9%, with a median follow-up period of 38.6 (8.6-62.1) mo.
CONCLUSION VA-ECMO can be used as a support in patients undergoing high-risk PCI as it is associated with favorable long-term patient survival.
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Affiliation(s)
- Yi-Xiong Huang
- Medical School of Chinese People’s Liberation Army, Beijing 100853, China
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Zheng-Ming Xu
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Li Zhao
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Yi Cao
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Yu Chen
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Yi-Gang Qiu
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Ying-Ming Liu
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Peng-Yu Zhang
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Jiang-Chun He
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
| | - Tian-Chang Li
- Department of Cardiology, Sixth Medical Center of Chinese People’s Liberation Army General Hospital, Beijing 100048, China
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12
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Scott-Herridge JA, McIntyre WF, Hiebert BM, Ducas J, Garber PJ. Does a Heart Team Improve Clinical Outcomes? Am J Cardiol 2022; 169:120-126. [PMID: 35168753 DOI: 10.1016/j.amjcard.2022.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 01/19/2023]
Abstract
Consultation by a Heart Team (HT) is a class I recommendation by the American College of Cardiology, American Heart Association, and the European Society of Cardiology for the management of patients with complex cardiac disease. Despite the class I recommendation, there is a paucity of data to support the role of an HT with only level C quality of evidence. This study was performed to follow patients who were referred for HT consultation and long-term outcomes in relation to whether the recommendation of the HT was followed or not. We performed a prospective analysis of our cohort of patients who underwent consultation by the HT. A total of 342 cases have been followed. Patient characteristics, referring physicians' favored treatment, and key outcomes were followed. A total of 336 patients were reviewed; 70.4% were male patients with a median age of 66.3 years and an average EuroSCORE II score of 7.2%. A total of 79.9% of the discussions resulted in a unanimous decision. The recommendations made by the HT differed from those documented by the referring physician in 54% of cases. In conclusion, recommendations made by the HT were followed in 269 cases (83.8%). There was a significant reduction in cardiac death (6.3% vs 15.3%, p = 0.042), composite cardiac outcome (23.4% vs 51.9%, p ≤0.001), and hospital admissions (10.4% vs 36.5%, p ≤0.001) when recommendations were followed. There was no statistical difference between the 2 groups when looking at noncardiac death, stroke, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, dialysis, or an emergency room visit.
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13
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Witberg G, Landes U, Codner P, Barbanti M, Valvo R, De Backer O, Ooms JF, McInerney A, Masiero G, Werner P, Armario X, Fiorina C, Arzamendi D, Santos-Martinez S, Baz JA, Steblovnik K, Mauri V, Adam M, Merdler I, Hein M, Ruile P, Russo M, Musumeci F, Sedaghat A, Sugiura A, Grasso C, Branca L, Estévez-Loureiro R, Amat-Santos IJ, Mylotte D, Andreas M, Bunc M, Tarantini G, Nombela-Franco L, Søndergaard L, Van Mieghem NM, Finkelstein A, Kornowski R. Clinical outcomes of transcatheter aortic valve implantation in patients younger than 70 years rejected for surgery: the AMTRAC registry. EUROINTERVENTION 2022; 17:1289-1297. [PMID: 34673502 PMCID: PMC9743236 DOI: 10.4244/eij-d-21-00613] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing. AIMS The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old. METHODS All patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 and June 2020 were stratified by age (</>70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups. RESULTS Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0±2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715). CONCLUSIONS Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications. ((ClinicalTrials.gov: NCT04031274).
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Affiliation(s)
- Guy Witberg
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Landes
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pablo Codner
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marco Barbanti
- Division of Cardiology, University of Catania, Catania, Italy
| | - Roberto Valvo
- Division of Cardiology, University of Catania, Catania, Italy
| | - Ole De Backer
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joris F Ooms
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Paul Werner
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Xavier Armario
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland
| | | | - Dabit Arzamendi
- Hospital de Sant Creu i Sant Pau Barcelona, Barcelona, Spain
| | | | - Jose A Baz
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Klemen Steblovnik
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Victor Mauri
- Department of Cardiology, Heart Centre, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Matti Adam
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ilan Merdler
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Manuel Hein
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | | | | | | | - Carmelo Grasso
- Division of Cardiology, University of Catania, Catania, Italy
| | - Luca Branca
- Cardiovascular Department, Spedali Civili, Brescia, Italy
| | | | | | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Martin Andreas
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Matjaž Bunc
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Lars Søndergaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ariel Finkelstein
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ran Kornowski
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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15
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e4-e17. [PMID: 34882436 DOI: 10.1161/cir.0000000000001039] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
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16
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 493] [Impact Index Per Article: 164.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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17
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2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:197-215. [PMID: 34895951 DOI: 10.1016/j.jacc.2021.09.005] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
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18
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Ma H, Lin S, Li X, Dou K, Yang W, Feng W, Liu S, Wu Y, Peng B, Zheng Z. Exploring optimal heart team protocol to improve decision-making stability for complex coronary artery disease: a sequential explanatory mixed method study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:739-749. [PMID: 34634101 DOI: 10.1093/ehjqcco/qcab074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022]
Abstract
AIMS Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. METHODS AND RESULTS This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. CONCLUSIONS Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kefei Dou
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Weixian Yang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Feng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Wu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Boshizhang Peng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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19
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Witberg G, Segev A, Barac YD, Raanani E, Assali A, Finkelstein A, Roguin A, Sahar G, Vaknin-Assa H, Bolotin G, Eitan A, Klempfner R, Goldenberg I, Kornowski R. Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease. Circ Cardiovasc Interv 2021; 14:e009686. [PMID: 33423541 DOI: 10.1161/circinterventions.120.009686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. METHODS This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. RESULTS Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. CONCLUSIONS Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.
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Affiliation(s)
- Guy Witberg
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Amit Segev
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Yaron D Barac
- Department of Cardiovascular and Thoracic Surgery (Y.D.B.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Ehud Raanani
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Abid Assali
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Department of Cardiology, Meir Medical Center, Kfar-Saba, Israel (A.A.)
| | - Ariel Finkelstein
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Department of Cardiology, Tel Aviv Medical Center, Israel (A.F.)
| | - Ariel Roguin
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel (A.R.)
| | - Gideon Sahar
- Department of Cardiac Surgery, Soroka Medical Center, Be'er-Sheva, Israel (G.S.).,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel (G.S.)
| | - Hana Vaknin-Assa
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Gil Bolotin
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiothoracic surgery, Rambam Health Care Campus, Haifa, Israel (G.B.)
| | - Amnon Eitan
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel (A.E.)
| | - Robert Klempfner
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Ilan Goldenberg
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Ran Kornowski
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
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20
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Beckmann A, Bitzer EM, Lederle M, Ihle P, Walker J, Marshall U, Horenkamp-Sonntag D, Schneider S, Zeymer U. Health Care Analysis on Myocardial Revascularization in Patients with Chronic Coronary Artery Disease: The Multicenter REVASK Study: Design and Protocol. Thorac Cardiovasc Surg 2020; 69:599-606. [PMID: 33339068 PMCID: PMC8519729 DOI: 10.1055/s-0040-1721391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are available for revascularization of coronary artery disease (CAD) with the aims to reduce cardiovascular morbidity and mortality and to improve disease-related quality of life in particular. The German National Care Guideline (NVL-cKHK) on chronic CAD recommends the establishment of so-called heart teams for decision making in myocardial revascularization to improve the quality of care. Preferred recommendations for PCI or CABG are given for different patient subgroups depending on patient characteristics, concomitant diseases, and coronary morphology. The myocardial revascularization study (REVASK) is a noninterventional cohort study on care of patients undergoing PCI or CABG based on retrospective statutory health insurance (SHI) routine data, registry data from the German Cardiac Society (DGK) resp., the German Society for Thoracic and Cardiovascular Surgery (DGTHG), combined with prospective primary data collection from health care providers and patients. The primary goal is to investigate whether and to which extent heart teams, consisting of cardiologists and cardiac surgeons, increase guideline adherence in decision making for myocardial revascularization. Ultimately the study project aims to improve patient care in terms of decision making for appropriate myocardial revascularization. Through the consistent implementation of the German National Care Guideline on chronic Coronary Artery Disease (NVL-cKHK) and the European Guidelines on myocardial revascularization, the reduction of morbidity, mortality and the reduced need for subsequent revascularization procedures are also desirable from a health economics perspective.
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Affiliation(s)
- Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery (GSTCVS), Berlin, Germany
| | | | | | - Peter Ihle
- PMV research group, University of Cologne, Cologne, Germany
| | - Jochen Walker
- Institute for Applied Health Research Berlin GmbH (InGef), Berlin, Germany
| | | | | | - Steffen Schneider
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
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21
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Dourado LOC, Pereira AC, Poppi NT, Cavalcante R, Gaiotto F, Dallan LAO, Bittencourt MS, Cesar LAM, Gowdak LHW. The Role of the Heart Team in Patients with Diffuse Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2020; 69:584-591. [PMID: 33225435 DOI: 10.1055/s-0040-1718936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis. METHODS Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based on individual scores, the Heart Team's and the specialists' scores were calculated and compared. RESULTS The examiners evaluated 154 coronary territories, of which 85 (55.2%) were protected. The Heart Team's accuracy for predicting the angiographic success of the surgery was 74.9%, almost equal to that of the surgeons alone (73.2%). Only the interventional cardiologist predicted left anterior descending territory grafting success. The Heart Team had good specificity and reasonable sensitivity, and the surgeons had high sensitivity and low specificity in predicting angiographic success. CONCLUSION The multispecialty Heart Team achieved good accuracy in predicting the angiographic coronary artery bypass graft success in patients with diffuse CAD, with a high specificity and reasonable sensitivity.
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Affiliation(s)
| | - Alexandre C Pereira
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Nilson Tavares Poppi
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Rafael Cavalcante
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Fabio Gaiotto
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | | | - Marcio Sommer Bittencourt
- Division of Internal Medicine, Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, Sao Paulo, Brazil
| | - Luiz Antonio M Cesar
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
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22
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Jahangiri M, Mani K, Yates MT, Nowell J. The EXCEL Trial: The Surgeons' Perspective. Eur Cardiol 2020; 15:e67. [PMID: 33294035 PMCID: PMC7689871 DOI: 10.15420/ecr.2020.34] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 01/06/2023] Open
Abstract
There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.
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Affiliation(s)
| | - Krishna Mani
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Martin T Yates
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Justin Nowell
- Department of Cardiac Surgery, St. George's Hospital London, UK
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23
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Affiliation(s)
- Julian Yeoh
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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24
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Tsang MB, Schwalm JD, Gandhi S, Sibbald MG, Gafni A, Mercuri M, Salehian O, Lamy A, Pericak D, Jolly S, Sheth T, Ainsworth C, Velianou J, Valettas N, Mehta S, Pinilla N, Yanagawa B, Zhang L, Chu V, Parry D, Whitlock R, Dyub A, Cybulsky I, Semelhago L, Ioannou K, Hameed A, Wright D, Mulji A, Darvish-Kazem S, Gupta N, Alshatti A, Natarajan MK. Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e2012749. [PMID: 32777060 PMCID: PMC7417969 DOI: 10.1001/jamanetworkopen.2020.12749] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. OBJECTIVE To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. MAIN OUTCOMES AND MEASURES The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. RESULTS Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). CONCLUSIONS AND RELEVANCE The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.
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Affiliation(s)
- Michael B. Tsang
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J. D. Schwalm
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sumeet Gandhi
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Matthew G. Sibbald
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Center for Health Economics and Policy Analysis, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dan Pericak
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sanjit Jolly
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tej Sheth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Velianou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Valettas
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shamir Mehta
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Natalia Pinilla
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Li Zhang
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Victor Chu
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Parry
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Dunedin Hospital, Otago, New Zealand
| | - Richard Whitlock
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Adel Dyub
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Irene Cybulsky
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lloyd Semelhago
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kostas Ioannou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Adnan Hameed
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Douglas Wright
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amin Mulji
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Saeed Darvish-Kazem
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Brampton Civic Hospital, William Osler Health System, Brampton, Ontario, Canada
| | - Nandini Gupta
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Alshatti
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Patterson T, McConkey HZR, Ahmed-Jushuf F, Moschonas K, Nguyen H, Karamasis GV, Perera D, Clapp BR, Roxburgh J, Blauth C, Young CP, Redwood SR, Pavlidis AN. Long-Term Outcomes Following Heart Team Revascularization Recommendations in Complex Coronary Artery Disease. J Am Heart Assoc 2020; 8:e011279. [PMID: 30943827 PMCID: PMC6507188 DOI: 10.1161/jaha.118.011279] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The Heart Team (HT) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease (CAD). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion. Methods and Results This observational study was conducted at St Thomas’ Hospital (London, UK). Case mixture included unprotected left main, 2‐vessel (including proximal left anterior descending artery) CAD, 3‐vessel CAD, or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy (OMT) alone, OMT+percutaneous coronary intervention (PCI), or OMT+coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23–39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3‐vessel CAD. Three‐year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT+PCI cohort, and 90.2% in the OMT+coronary artery bypass grafting cohort (92 of 102). Conclusions In our experience, the HT approach involved a careful selection process resulting in appropriate patient‐specific decision making and good long‐term outcomes in patients with complex CAD.
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Affiliation(s)
- Tiffany Patterson
- 1 Division of Cardiovascular The Rayne Institute BHF Centre of Research Excellence King's College London St. Thomas' Hospital London United Kingdom
| | - Hannah Z R McConkey
- 1 Division of Cardiovascular The Rayne Institute BHF Centre of Research Excellence King's College London St. Thomas' Hospital London United Kingdom
| | - Fiyyaz Ahmed-Jushuf
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - Konstantinos Moschonas
- 3 Department of Cardiology King's College Hospital NHS Foundation Trust London United Kingdom
| | - Hanna Nguyen
- 1 Division of Cardiovascular The Rayne Institute BHF Centre of Research Excellence King's College London St. Thomas' Hospital London United Kingdom
| | | | - Divaka Perera
- 1 Division of Cardiovascular The Rayne Institute BHF Centre of Research Excellence King's College London St. Thomas' Hospital London United Kingdom
| | - Brian R Clapp
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - James Roxburgh
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - Christopher Blauth
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - Christopher P Young
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - Simon R Redwood
- 1 Division of Cardiovascular The Rayne Institute BHF Centre of Research Excellence King's College London St. Thomas' Hospital London United Kingdom
| | - Antonis N Pavlidis
- 2 Department of Cardiothoracic Guy's and St Thomas' NHS Foundation Trust London United Kingdom
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26
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Milojevic M, Milacic P, Petrovic I, Bojic M, Milojevic A, Nikolic A, Sandner S, Sousa-Uva M. Mapping decision making for bypass surgery in the era of interventional medicine: towards an integrative model of patient-centeredness. Minerva Cardioangiol 2020; 68:469-479. [PMID: 32657555 DOI: 10.23736/s0026-4725.20.05228-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article reviews the context and evidence of recent myocardial revascularization trials on PCI versus CABG with particular emphasis on patient selection and treatment of surgical patients. Moreover, one of our intended purposes is to identify the values underpinning the integrated care model, which incorporates decision to proceed with surgical myocardial revascularization in conjunction with established pillars of the use of optimal surgical techniques, and aggressive risk-factor modification through guideline-directed pharmacological therapies and lifestyle modifications.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia - .,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands -
| | - Petar Milacic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Ivana Petrovic
- Department of Cardiothoracic Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Milovan Bojic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | | | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, North Macedonia
| | - Sigrid Sandner
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Miguel Sousa-Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Lisbon, Portugal.,Department of Surgery and Physiology, Cardiovascular Research Center, Faculty of Medicine, Porto University, Porto, Portugal
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27
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3841] [Impact Index Per Article: 960.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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28
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Riley RF, Henry TD, Mahmud E, Kirtane AJ, Brilakis ES, Goyal A, Grines CL, Lombardi WL, Maran A, Rab T, Tremmel JA, Truesdell AG, Yeh RW, Zhao DX, Jaffer FA. SCAI
position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease. Catheter Cardiovasc Interv 2020; 96:346-362. [DOI: 10.1002/ccd.28994] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Affiliation(s)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education The Christ Hospital Cincinnati Ohio USA
| | - Ehtisham Mahmud
- Sulpizio Cardiovascular Center University of California San Diego La Jolla California USA
| | - Ajay J. Kirtane
- Center for Interventional Vascular Therapy Columbia University Medical Center New York New York USA
| | | | | | | | | | - Anbukarasi Maran
- Medical University of South Carolina North Charleston South Carolina USA
| | | | | | | | - Robert W. Yeh
- Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - David X. Zhao
- Wake Forest University School of Medicine Winston‐Salem North Carolina USA
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29
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Young MN, Kolte D, Cadigan ME, Laikhter E, Sinclair K, Pomerantsev E, Fifer MA, Sundt TM, Yeh RW, Jaffer FA. Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation. J Am Heart Assoc 2020; 9:e014738. [PMID: 32308096 PMCID: PMC7428540 DOI: 10.1161/jaha.119.014738] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background The Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision-making and outcomes of patients based on this strategy. Methods and Results One hundred sixty-six high-risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery (STS-PROM/SYNTAX) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end-stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty-seven (52.4%) patients had New York Heart Association III-IV and 112 (67.5%) had Canadian Cardiovascular Society III-IV symptomatology. Sixty-seven (40.4%) patients had left main and 118 (71.1%) had 3-vessel coronary artery disease. The median STS-PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy-nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS-PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In-hospital and 30-day mortality was 3.9% and 4.8%, respectively. Conclusions Integrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence-based management within this team-based construct.
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Affiliation(s)
- Michael N Young
- Division of Cardiology Dartmouth-Hitchcock Medical Center Geisel School of Medicine at Dartmouth Lebanon NH
| | - Dhaval Kolte
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Mary E Cadigan
- Division of Cardiology Massachusetts General Hospital Boston MA
| | | | - Kevin Sinclair
- Division of Cardiology Massachusetts General Hospital Boston MA
| | | | - Michael A Fifer
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Thoralf M Sundt
- Division of Cardiology Massachusetts General Hospital Boston MA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Farouc A Jaffer
- Division of Cardiology Massachusetts General Hospital Boston MA
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30
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Exploring Current Evidence on the Past, the Present, and the Future of the Heart Team: A Narrative Review. Cardiovasc Ther 2020; 2020:9241081. [PMID: 31969934 PMCID: PMC6964708 DOI: 10.1155/2020/9241081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Including healthcare professionals dealing with cardiovascular diseases, Heart Team is a concept/structure designed for selecting diagnostic strategies, facilitating therapeutic decisions, and improving cardiovascular outcomes in patients with complex heart pathologies, requiring input from different subspecialties and the necessity of a multidisciplinary approach. The aim of this narrative review is to search for and to summarize current evidence regarding Heart Team and to underline the future directions for the development of this concept. Methods We searched the electronic database of PubMed, SCOPUS, and Cochrane CENTRAL for studies including Heart Team. Forty-eight studies were included, if reference was made to Heart Team structure and functionality. Results We depicted the structure and the timeline of Heart Team, along with actual evidence-based recommendations from European Guidelines. We underlined the importance of quality of knowledge-sharing and decision-making inside the Team, analyzing bad decisions which did not reflect members' true beliefs due to "uniformity pressure, closed mindedness, and illusion of invulnerability." The observation that Guidelines' indications regarding Heart Team carry a level C indication underlines the very future of this Team: randomized controlled trials proving solid benefits in an evidence-based world. Conclusions Envisioned as a tool for optimizing the management of various complex cardiovascular pathologies, Heart Team should simplify and facilitate the activity in the cardiovascular ward. Finally, these facts should be translated into better cardiovascular outcomes and a lower psychological distress among Team participants. Despite all future changes, there must always be a constant part: the patient should remain at the very center of the Team.
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Affiliation(s)
- Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Guy Witberg
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 300] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Domingues CT, Milojevic M, Thuijs DJFM, van Mieghem NM, Daemen J, van Domburg RT, Kappetein AP, Head SJ. Heart Team decision making and long-term outcomes for 1000 consecutive cases of coronary artery disease. Interact Cardiovasc Thorac Surg 2019; 28:206-213. [DOI: 10.1093/icvts/ivy237] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Carina T Domingues
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Netherlands
| | - Ron T van Domburg
- Department of Cardiology, Erasmus University Medical Center, Netherlands
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2018; 55:4-90. [PMID: 30165632 DOI: 10.1093/ejcts/ezy289] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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