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Gibbs NK, Griffin S, Gutacker N, Villaseñor A, Walker S. The Health Impact of Waiting for Elective Procedures in the NHS in England: A Modeling Framework Applied to Coronary Artery Bypass Graft and Total Hip Replacement. Med Decis Making 2024; 44:572-585. [PMID: 38855915 PMCID: PMC11283740 DOI: 10.1177/0272989x241256639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/03/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION The aim of this study is to demonstrate a practical framework that can be applied to estimate the health impact of changes in waiting times across a range of elective procedures in the National Health Service (NHS) in England. We apply this framework by modeling 2 procedures: coronary artery bypass graft (CABG) and total hip replacement (THR). METHODS We built a Markov model capturing health pre- and postprocedure, including the possibility of exiting preprocedure to acute NHS care or self-funded private care. We estimate the change in quality-adjusted life-years (QALYs) over a lifetime horizon for 10 subgroups defined by sex and Index of Multiple Deprivation quintile groups and for 7 alternative scenarios. We include 18 wk as a baseline waiting time consistent with current NHS policy. The model was populated with data from routinely collected data sets where possible (Hospital Episode Statistics, Patient-Reported Outcome Measures, and Office for National Statistics Mortality records), supplemented by the academic literature. RESULTS Compared with 18 wk, increasing the wait time to 36 wk resulted in a mean discounted QALY loss in the range of 0.034 to 0.043 for CABG and 0.193 to 0.291 for THR. The QALY impact of longer NHS waits was greater for those living in more deprived areas, partly as fewer patients switch to private care. DISCUSSION/CONCLUSION The proposed framework was applied to 2 different procedures and patient populations. If applied to an expanded group of procedures, it could provide decision makers with information to inform prioritization of waiting lists. There are a number of limitations in routine data on waiting for elective procedures, primarily the lack of information on people still waiting. HIGHLIGHTS We present a modeling framework that allows for an estimation of the health impact (measured in quality-adjusted life-years) of waiting for elective procedures in the NHS in England.We apply our model to waiting for coronary artery bypass graft (CABG) and total hip replacement (THR). Increasing the wait for THR results in a larger health loss than an equivalent increase in wait for CABG.This model could potentially be used to estimate the impact across an expanded group of procedures to inform prioritization of activities to reduce waiting times.
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Affiliation(s)
- Naomi Kate Gibbs
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Adrián Villaseñor
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, Heslington, York, UK
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Russo M, Watson K, Richards K, Olive RR, Krausova B, Kumar R, Burridge J, Goulding L, Chua KC, Hardy D, Vassilios A, Kamran B, Bhudia S, Alia N, Habib K, Sevdalis N, Petrou M. Study protocol for a cross-sectional online survey investigating patient preferences and experiences of waiting for elective cardiac surgery. BMJ Open 2024; 14:e079692. [PMID: 38443077 PMCID: PMC11146383 DOI: 10.1136/bmjopen-2023-079692] [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] [Received: 09/08/2023] [Accepted: 01/31/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION Being on a waiting list for elective (planned) cardiac surgery can be physically and psychologically challenging for patients. Research suggests that stress associated with waiting for surgery is dependent on different individual and contextual factors. However, most data on patients' experiences of waiting for surgery and preferences for waiting list management derives from non-cardiac clinical populations. The aim of the current study is to explore patients' experiences of being on a waiting list for elective cardiac surgery, and their views on how the waiting experience could be improved in the future. This work will inform the patient management strategy during the waiting period for surgery across the four major hospitals in London directly involved in this study, and potentially beyond by transferring learning to other services. METHODS AND ANALYSIS This is a mixed-methods study that will collect quantitative and qualitative data using a cross-sectional online survey. Patients who are on waiting lists for elective surgery across four major cardiac surgery departments in London hospitals, and are at least 18 years old, will be invited by their healthcare team via text message or letter to complete the survey. The target sample size of non-randomly selected participants will be 268. Bivariable and multivariable regression models will be used to assess associations between survey items measuring the impact of the cardiac condition on specific life domains (eg, daily activities, social and family relationships, hobbies, sexual life), anxiety and depression symptoms as measured by the Patient Health Questionnaire-4 and survey items evaluating experiences of health services. Data on experience and preferences for improvements to the waiting experience will be analysed with qualitative content analysis using an inductive approach. ETHICS AND DISSEMINATION This study was reviewed and granted ethical approval by the East of England-East Cambridge Research Ethics Committee. Findings from this study will be disseminated through peer-reviewed journals, a research website and social media and with an online event engaging patients, members of the public, healthcare professionals and other relevant stakeholders. TRIAL REGISTRATION NUMB NCT05996640.
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Affiliation(s)
- Manuela Russo
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kathryn Watson
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Katie Richards
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rachel Rowan Olive
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Barbora Krausova
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | | | - Lucy Goulding
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kia-Chong Chua
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, King's College London, London, UK
| | - David Hardy
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Baig Kamran
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sunil Bhudia
- Royal Brompton & Harefield hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Noorani Alia
- King's College Hospital NHS Foundation Trust, London, UK
| | - Khan Habib
- King's College Hospital NHS Foundation Trust, London, UK
| | - Nick Sevdalis
- Centre for Behavioural and Implementation Science Interventions, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mario Petrou
- Royal Brompton & Harefield hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Friedman T, Dann EJ, Bitton-Worms K, Makhoul M, Glam R, Weis A, Tam DY, Bolotin G. Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia. Br J Anaesth 2023; 131:981-988. [PMID: 37838604 DOI: 10.1016/j.bja.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/02/2023] [Accepted: 09/14/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Reducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery. METHODS This double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24-72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery. RESULTS The 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl-1 and 9.3 (1) g dl-1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl-1 and 11.8 (1.5) g dl-1, respectively (P=0.012). CONCLUSIONS In patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1-3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration. CLINICAL TRIAL REGISTRATION NCT02939794.
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Affiliation(s)
- Tom Friedman
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Eldad J Dann
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - Maged Makhoul
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Roi Glam
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Anastasia Weis
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Bakaeen FG, Ruel M, Calhoon JH, Girardi LN, Guyton R, Hui D, Kelly RF, MacGillivray TE, Malaisrie SC, Moon MR, Sabik JF, Smith PK, Svensson LG, Szeto WY. STS/AATS-Endorsed Rebuttal to 2023 ACC/AHA Chronic Coronary Disease Guideline: A Missed Opportunity to Present Accurate and Comprehensive Revascularization Recommendations. Ann Thorac Surg 2023; 116:675-678. [PMID: 37530679 DOI: 10.1016/j.athoracsur.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Faisal G Bakaeen
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weil Cornell Medical Center, New York, New York
| | - Robert Guyton
- Cardiothoracic Surgery, The Emory Clinic, Inc, Atlanta, Georgia
| | - Dawn Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Thomas E MacGillivray
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC
| | | | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter K Smith
- Department of Cardiothoracic Surgery, Duke University, Durham, North Carolina
| | - Lars G Svensson
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Y Szeto
- Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Bakaeen FG, Ruel M, Calhoon JH, Girardi LN, Guyton R, Hui D, Kelly RF, MacGillivray TE, Malaisrie SC, Moon MR, Sabik JF, Smith PK, Svensson LG, Szeto WY. STS/AATS-endorsed rebuttal to 2023 ACC/AHA Chronic Coronary Disease Guideline: A missed opportunity to present accurate and comprehensive revascularization recommendations. J Thorac Cardiovasc Surg 2023; 166:1115-1118. [PMID: 37530691 DOI: 10.1016/j.jtcvs.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Faisal G Bakaeen
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Tex
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weil Cornell Medical Center, New York, NY
| | - Robert Guyton
- Cardiothoracic Surgery, The Emory Clinic, Inc, Atlanta, Ga
| | - Dawn Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Tex
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minn
| | - Thomas E MacGillivray
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC
| | | | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter K Smith
- Department of Cardiothoracic Surgery, Duke University, Durham, NC
| | - Lars G Svensson
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Y Szeto
- Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
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Agarwal R, Mudgal S, Arnav A, Ranjan N. Coronary artery bypass grafting in active or recent COVID-19 infection: a systematic review. Indian J Thorac Cardiovasc Surg 2023; 39:350-358. [PMID: 37342488 PMCID: PMC9995725 DOI: 10.1007/s12055-023-01495-7] [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: 08/30/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 03/11/2023] Open
Abstract
Introduction Even though there have been few studies on coronary artery bypass grafting (CABG), data on patients with coronavirus disease-2019 (COVID-19) infection show that cardiac surgery has poor outcomes in this subset. From the available studies in the literature, we conducted a systematic review with the aim of determining the outcome of COVID-19 patients who underwent CABG. Methods Between December 2019 and October 2022, searches were conducted in PubMed, the Directory of Open Access Journals, and Google Scholar to find studies reporting results of COVID-19 patients undergoing CABG. We extracted data on the clinical profile and outcomes of the patients from the eligible studies. The quality of the studies was assessed using a standardised tool. Results The total sample size across the 12 included studies was 99 patients who underwent CABG in active disease or within 30 days of COVID-19 infection. The median and interquartile range (IQR) for the length of time spent on a mechanical ventilator, stay in the intensive care unit (ICU), and the total hospital stay were 0.9 (0.47-2), 4.5 (2.5-8), and 12.5 (8.5-22.5) days respectively. Seventy-six patients developed postoperative complications, and there were eleven deaths. Conclusion The findings of the present study indicate that mortality risk goes down when the time between COVID-19 diagnosis and surgery increases. When compared to data from other high-risk urgent or emergent CABG patients around the world who were not infected with COVID-19, patients who underwent CABG in the COVID-19 subgroup had similar postoperative outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01495-7.
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Affiliation(s)
- Rajat Agarwal
- Department of Cardiothoracic Surgery, All India Institute of Medical Sciences (AIIMS) Deoghar, PTI Campus, Jasidih, Deoghar, 814142 Jharkhand India
| | - Shiv Mudgal
- College of Nursing, All India Institute of Medical Sciences (AIIMS) Deoghar, Deoghar, Jharkhand 814142 India
| | - Amiy Arnav
- Department of Surgical Oncology, All India Institute of Medical Sciences (AIIMS) Deoghar, Deoghar, Jharkhand 814142 India
| | - Nishit Ranjan
- Department of General Surgery, All India Institute of Medical Sciences (AIIMS) Deoghar, Deoghar, Jharkhand 814142 India
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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:e002050. [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] [MESH Headings] [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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Sobolev B, Kuramoto L. Time of coronary revascularization: methodology of a mediation analysis study. CMAJ Open 2022; 10:E1052-E1058. [PMID: 36735232 PMCID: PMC9828946 DOI: 10.9778/cmajo.20210183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The advantage of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI), established in trials, may not be generalizable to populations in which the method of treatment determines the time to treatment. We sought to describe the methodology of a population-based observational study for assessing how changes in time to treatment may affect the comparative effectiveness of these 2 methods of coronary revascularization. METHODS We propose a framework of causal mediation analysis to compare the outcomes of choosing CABG over PCI, if patients selected for either method waited the same amount of time had they undergone a PCI. We will include patients who underwent a first-time, nonurgent isolated CABG or single-session PCI for multivessel or left main coronary artery disease from January 2001 to December 2016, in British Columbia. We will use absolute risk difference as a measure of the total effect of choosing CABG over PCI and partition it into the direct effect of the treatment choice and the effect mediated by the treatment-specific timing. INTERPRETATION Understanding how time to treatment mediates the relation between method of revascularization and outcomes will have implications for treatment selection, resource allocation and planning benchmarks. Findings on the benefits and risks of performing PCI or CABG within a certain time will guide multidisciplinary teams in determining the appropriate revascularization method for individual patients.
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Affiliation(s)
- Boris Sobolev
- School of Population and Public Health (Sobolev), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Lisa Kuramoto
- School of Population and Public Health (Sobolev), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC
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Hoefsmit PC, Schretlen S, Burchell G, van den Heuvel J, Bonjer J, Dahele M, Zandbergen R. Can Quality Improvement Methodologies Derived from Manufacturing Industry Improve Care in Cardiac Surgery? A Systematic Review. J Clin Med 2022; 11:jcm11185350. [PMID: 36142997 PMCID: PMC9502537 DOI: 10.3390/jcm11185350] [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] [Received: 08/18/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Healthcare is required to be effectively organised to ensure that growing, aging and medically more complex populations have timely access to high-quality, affordable care. Cardiac surgery is no exception to this, especially due to the competition for and demand on hospital resources, such as operating rooms and intensive care capacity. This is challenged more since the COVID-19 pandemic led to postponed care and prolonged waiting lists. In other sectors, Quality Improvement Methodologies (QIM) derived from the manufacturing industry have proven effective in enabling more efficient utilisation of existing capacity and resources and in improving the quality of care. We performed a systematic review to evaluate the ability of such QIM to improve care in cardiac surgery. Methods: A literature search was performed in PubMed, Embase, Clarivate Analytics/Web of Science Core Collection and Wiley/the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. Results: Ten articles were identified. The following QIM were used: Lean, Toyota Production System, Six Sigma, Lean Six Sigma, Root Cause Analysis, Kaizen and Plan-Do-Study-Act. All reported one or more relevant improvements in patient-related (e.g., infection rates, ventilation time, mortality, adverse events, glycaemic control) and process-related outcomes (e.g., shorter waiting times, shorter transfer time and productivity). Elements to enhance the success included: multidisciplinary team engagement, a patient-oriented, data-driven approach, a sense of urgency and a focus on sustainability. Conclusions: In all ten papers describing the application of QIM initiatives to cardiac surgery, positive results, of varying magnitude, were reported. While the consistency of the available data is encouraging, the limited quantity and heterogenous quality of the evidence base highlights that more rigorous evaluation, including how best to employ manufacturing industry-derived QIM in cardiac surgery is warranted.
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Affiliation(s)
- Paulien Christine Hoefsmit
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centre, 1081 HV Amsterdam, The Netherlands
- Correspondence:
| | - Stijn Schretlen
- Integrated Health Solutions, Medtronic Inc., 5616 VB Eindhoven, The Netherlands
| | - George Burchell
- Medical Library, Vrije Universiteit, 1081 HV Amsterdam, The Netherlands
| | - Jaap van den Heuvel
- Department of Healthcare Management, University of Amsterdam Business School, 1018 TV Amsterdam, The Netherlands
| | - Jaap Bonjer
- Department of Surgery, Amsterdam University Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Max Dahele
- Department of Radiation Oncology, Amsterdam University Medical Centre, 1081 HV Amsterdam, The Netherlands
| | - Reinier Zandbergen
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centre, 1081 HV Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Centre, 1081 HV Amsterdam, The Netherlands
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Böning A, Falk V, Gummert J, Markewitz A, Heinemann M, Beckmann A. [COVID-19: retrospective analysis of cardiac surgery capacity in German heart centers]. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022; 36:292-297. [PMID: 35968031 PMCID: PMC9362024 DOI: 10.1007/s00398-022-00527-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/03/2022]
Abstract
Background For documentation of COVID-19 pandemic-related changes in cardiac surgery in Germany, the German Society for Thoracic and Cardiovascular Surgery carried out a structured survey. Methods From 79 German institutions for cardiac surgery, 53 took part in the survey. The cut-off date before the pandemic was taken as 1 January 2020 and 30 April 2021 as the cut-off date for data recruitment. At this point of time, the third wave of the pandemic in Germany had already ebbed away and the return to routine surgery seemed to be foreseeable. Results On 1 January 2020, in 53 German cardiac surgery departments 800 intensive care beds were allocated. In April 2021, this capacity was reduced by 25.6% to 595 beds. Accordingly, the number of operating rooms for cardiac surgery procedures was reduced from 207 to 152 (-26.9%) during the first two lockdowns. During the COVID-19 pandemic, hospital facilities were restructured: 50.9% of participants delegated medical personnel, and 75.5% had to transfer nursing personnel to special COVID-19 facilities in their hospitals. Conclusion From the start of the COVID-19 pandemic until the end of the third wave during April 2021, cardiac surgery in Germany changed profoundly, leading to a substantial reduction of intensive care beds and operating rooms for patients requiring cardiac surgery.
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Affiliation(s)
- Andreas Böning
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
- Klinik für Herz‑, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Rudolf-Buchheim-Str. 7, 35385 Gießen, Deutschland
| | - Volkmar Falk
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
| | - Jan Gummert
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
| | - Andreas Markewitz
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
| | - Markus Heinemann
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
| | - Andreas Beckmann
- Langenbeck-Virchow-Haus, Deutsche Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie, Luisenstr. 58/59, 10117 Berlin, Deutschland
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Martín Gutiérrez E, Castaño Ruiz M, Hornero Sos F, Laguna Núñez G, Barquero Aroca JM, Rodríguez-Roda Stuart J, Berastegui García E, Cuerpo Caballero G, Carnero Alcázar M, Dalmau Sorlí MJ, García Fuster R, Gutiérrez Carretero E, Garrido Jiménez JM, Gualis Cardona J, Bautista Hernández V, Sánchez Pérez R, López Menéndez J, Ortiz Berbel D. Criterios de ordenación temporal de las intervenciones quirúrgicas en patología cardiovascular y endovascular adquirida. Versión 2022. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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12
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Yates MT, Balmforth D, Kirmani BH, Acharya M, Jeganathan R, Ngaage D, Kanani M, Deglurkar I, Lopez-Marco A, Sanders J, Ye Oo A. A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic. J R Soc Med 2022; 115:348-353. [PMID: 35485431 DOI: 10.1177/01410768221089016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN A multi-centre prospective cohort study. SETTING The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES Primary outcome was surgery, percutaneous therapy or death at one year. METHODS Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.
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Affiliation(s)
- Martin T Yates
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Damian Balmforth
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | | | | | | | - Dumbor Ngaage
- Hull and East Yorkshire NHS Trust, Hull, HU3 2JZ, UK
| | - Mayzar Kanani
- James Cook University Hospital, Middlesbrough, TS4 3BW, UK
| | - Indu Deglurkar
- University Hospital of Wales, Heath Park Way, Cardiff, CF14 4XW, UK
| | - Ana Lopez-Marco
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Julie Sanders
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University of London, London, E1 4NS, UK
| | - Aung Ye Oo
- St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Queen Mary University of London, London, E1 4NS, UK
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13
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Zeitouni M, Collet JP. Pretreatment in the Setting of Non-ST-Elevated Acute Coronary Syndrome-When It Is Time to Change. JAMA Netw Open 2021; 4:e2134472. [PMID: 34797373 DOI: 10.1001/jamanetworkopen.2021.34472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de cardiologie (AP-HP), Paris, France
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14
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Schretlen S, Hoefsmit P, Kats S, van Merode G, Maessen J, Zandbergen R. Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare. BMJ Open Qual 2021; 10:bmjoq-2021-001342. [PMID: 34462263 PMCID: PMC8407222 DOI: 10.1136/bmjoq-2021-001342] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/09/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled. METHOD A multifunctional project team used the data-driven LSS process improvement methodology and followed the 'DMAIC' improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an 'interrupted time series' study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant. RESULTS Last-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005). CONCLUSION This study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.
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Affiliation(s)
- Stijn Schretlen
- Integrated Health Solutions, Medtronic plc, Maastricht, Nederland, The Netherlands .,Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Paulien Hoefsmit
- Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Suzanne Kats
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Geofridus van Merode
- Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Jos Maessen
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
| | - Reinier Zandbergen
- Heart+Vascular Centre, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands.,Cardiothoracic Surgery, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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15
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Sun LY, Eddeen AB, Wijeysundera HC, Mamas MA, Tam DY, Mesana TG. Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist. CMAJ 2021; 193:E1333-E1340. [PMID: 34462293 PMCID: PMC8432314 DOI: 10.1503/cmaj.210170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery. METHODS We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection. RESULTS Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points. INTERPRETATION We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.
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Affiliation(s)
- Louise Y Sun
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont.
| | - Anan Bader Eddeen
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Harindra C Wijeysundera
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Mamas A Mamas
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Derrick Y Tam
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
| | - Thierry G Mesana
- Division of Cardiac Anesthesiology (Sun), University of Ottawa Heart Institute and the School of Epidemiology and Public Health, University of Ottawa; ICES uOttawa (Sun, Bader Eddeen), Ottawa, Ont.; ICES Central (Wijeysundera, Tam); Schulich Heart Program (Wijeysundera), Sunnybrook Health Sciences Centre; Division of Cardiology (Wijeysundera), Department of Medicine and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.; Keele Cardiovascular Research Group (Mamas), Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, UK; Department of Cardiology (Mamas), Royal Stoke University Hospital, Stoke-on-Trent, UK; Division of Cardiac Surgery (Tam), Sunnybrook Health Sciences Centre, Toronto, Ont.; Division of Cardiac Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont
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16
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Yuroong A, Asdornwised U, Pinyopasakul W, Wongkornrat W, Chansatitporn N. The Effectiveness of the Transitional Care Program Among People Awaiting Coronary Artery Bypass Graft Surgery: A Randomized Control Trial. J Nurs Scholarsh 2021; 53:585-594. [PMID: 34013579 DOI: 10.1111/jnu.12673] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE This study examined the effectiveness of the Transitional Care Program (TCP) on the anxiety, depression, cardiac self-efficacy, number of hospitalizations, and satisfaction with care among people awaiting elective coronary artery bypass graft (CABG) surgery. DESIGN The study design was a randomized controlled trial. METHODS The participants with coronary artery disease who met the study criteria (n = 104) were randomly assigned to the intervention group (n = 52) receiving the TCP plus routine care, or the control group (n = 52) receiving routine care only. The TCP, developed based on the Transitional Care Model, comprised hospital discharge planning and six weekly home telephone follow-ups to provide health education, counseling, monitoring, and emotional support tailored to the individual's needs. Data were collected at baseline, and then at weeks 1, 6, and 8 after program enrollment. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and the Z test. FINDINGS The intervention group had lower anxiety and depression than did the control group at weeks 1, 6, and 8 after program enrollment. At weeks 6 and 8, the intervention group exhibited higher cardiac self-efficacy and satisfaction with care than the control group. Further, the intervention group had a significantly lower number of hospitalizations than the control group at week 8. CONCLUSIONS The TCP can reduce anxiety, depression, and number of hospitalizations, while increasing cardiac self-efficacy and satisfaction with care among people awaiting CABG. CLINICAL RELEVANCE Nurses are in a pivotal position to make care transitions safer. Provision of discharge education and regular telephone contacts could enhance positive outcomes regarding patients awaiting elective cardiac surgery.
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Affiliation(s)
- Arisara Yuroong
- Phi Omega at-Large, PhD Candidate, Faculty of Nursing, Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Usavadee Asdornwised
- Phi Omega at-Large, Associate Professor, Faculty of Nursing, Mahidol University, Bangkok, Thailand
| | - Wanpen Pinyopasakul
- Phi Omega at-Large, Associate Professor, Faculty of Nursing, Mahidol University, Bangkok, Thailand
| | - Wanchai Wongkornrat
- Assistant Professor, Cardiothoracic Division, Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Natkamol Chansatitporn
- Assistant Professor, Department of Biostatistics, Faculty of Public Health, Mahidol University, Bangkok, Thailand
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17
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Čulić V, AlTurki A, Proietti R. Public health impact of daily life triggers of sudden cardiac death: A systematic review and comparative risk assessment. Resuscitation 2021; 162:154-162. [PMID: 33662523 DOI: 10.1016/j.resuscitation.2021.02.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/12/2021] [Accepted: 02/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts. METHODS We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used. RESULTS Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95% CI 1.2-29.3) to physical exertion, 6.9% (95% CI 0.3-25.0) to cocaine, 6% (95% CI 1.2-14.6) to episodic coffee consumption, 3% (95% CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95% CI -0.9 to 12.9) to amphetamines, 0.9% (95% CI -4.9 to 12.5) to cannabis, and 0.3% (95% CI 0.2-0.4) to influenza infections. CONCLUSIONS In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.
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Affiliation(s)
- Viktor Čulić
- Department of Cardiology and Angiology, University Hospital Centre Split, Split, Croatia; University of Split School of Medicine, Split, Croatia.
| | - Ahmed AlTurki
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
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18
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Makhdoum A, Tam DY, Fremes SE. Wicked problems and proportionality: Is the lesser of two evils the best we can do? J Thorac Cardiovasc Surg 2021; 161:e231-e232. [PMID: 33268115 PMCID: PMC7580685 DOI: 10.1016/j.jtcvs.2020.06.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Ahmad Makhdoum
- Division of Cardiac Surgery, Schulich Heart Centre; Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre; Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre; Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Moreno R, Díez JL, Diarte JA, Macaya F, de la Torrre Hernández JM, Rodríguez-Leor O, Trillo R, Alonso-Briales J, Amat-Santos I, Romaguera R, Díaz JF, Vaquerizo B, Ojeda S, Cruz-González I, Morena-Salas D, Pérez de Prado A, Sarnago F, Portero P, Gutierrez-Barrios A, Alfonso F, Bosch E, Pinar E, Ruiz-Arroyo JR, Ruiz-Quevedo V, Jiménez-Mazuecos J, Lozano F, Rumoroso JR, Novo E, Irazusta FJ, García Del Blanco B, Moreu J, Ballesteros-Pradas SM, Frutos A, Villa M, Alegría-Barrero E, Lázaro R, Paredes E. Consequences of canceling elective invasive cardiac procedures during Covid-19 outbreak. Catheter Cardiovasc Interv 2020; 97:927-937. [PMID: 33336506 DOI: 10.1002/ccd.29433] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/16/2020] [Accepted: 11/29/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND During COVID-19 pandemic in Spain, elective procedures were canceled or postponed, mainly due to health care systems overwhelming. OBJECTIVE The objective of this study was to evaluate the consequences of interrupting invasive procedures in patients with chronic cardiac diseases due to the COVID-19 outbreak in Spain. METHODS The study population is comprised of 2,158 patients that were pending on elective cardiac invasive procedures in 37 hospitals in Spain on the 14th of March 2020, when a state of alarm and subsequent lockdown was declared in Spain due to the COVID-19 pandemic. These patients were followed-up until April 31th. RESULTS Out of the 2,158 patients, 36 (1.7%) died. Mortality was significantly higher in patients pending on structural procedures (4.5% vs. 0.8%, respectively; p < .001), in those >80 year-old (5.1% vs. 0.7%, p < .001), and in presence of diabetes (2.7% vs. 0.9%, p = .001), hypertension (2.0% vs. 0.6%, p = .014), hypercholesterolemia (2.0% vs. 0.9%, p = .026) [Correction added on December 23, 2020, after first online publication: as per Dr. Moreno's request changes in p-values were made after original publication in Abstract.], chronic renal failure (6.0% vs. 1.2%, p < .001), NYHA > II (3.8% vs. 1.2%, p = .001), and CCS > II (4.2% vs. 1.4%, p = .013), whereas was it was significantly lower in smokers (0.5% vs. 1.9%, p = .013). Multivariable analysis identified age > 80, diabetes, renal failure and CCS > II as independent predictors for mortality. CONCLUSION Mortality at 45 days during COVID-19 outbreak in patients with chronic cardiovascular diseases included in a waiting list due to cancellation of invasive elective procedures was 1.7%. Some clinical characteristics may be of help in patient selection for being promptly treated when similar situations happen in the future.
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Affiliation(s)
- Raúl Moreno
- Hospital Universitario La Paz, IdiPAZ, CIBER-CV, Madrid, Spain
| | | | | | | | | | | | - Ramiro Trillo
- Hospital Clínico Universitario, Santiago de Compostela, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eduard Bosch
- Corporació Sanitaria Parc Tauli, Sabadell, Spain
| | | | | | | | | | | | | | | | | | | | - José Moreu
- Hospital Virgen de la Salud, Toledo, Spain
| | | | | | | | - Eduardo Alegría-Barrero
- Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain.,Hospital Ruber Internacional, Madrid, Spain
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20
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Sahu MK, Vaswani P, Satsangi A, Singh SP, Rajashekar P, Devagourou V, Choudhary SK. Cardiac Surgery Conduct during COVID-19 Pandemic. JOURNAL OF CARDIAC CRITICAL CARE TSS 2020. [DOI: 10.1055/s-0040-1721183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Health care is seriously affected by the coronavirus disease 2019 (COVID-19) pandemic with alarming effects upon conduct of cardiac surgery. The initial resource conservation strategy has to modify for handling the surging case load due to deference of routine care in the face of pandemic.
Methods The cardiac surgical practice during the lockdown period (from 25th march till 25th June) at a tertiary care centre was observed. The cardiac diagnosis of the ones operated, conduct algorithm, and working policy were analyzed. Descriptive statistics was applied to calculate the percentages of different case subsets in both adult and pediatric groups.
Results A total of 93 cardiac patients were consecutively operated during the 3 months’ period in two cardiac theatres of a total eight dedicated and were rotated cyclically. A total of 37 (39.78%) adult cardiac surgeries were performed out of 93 cases, with coronary artery bypass grafting (11.83%: 11/93) and valvular heart diseases (11.83%: 11/93) constituting the majority. Pediatric cardiac surgeries constituted 56 cases (60.21%) which comprised of arterial switch operation (19.35%), total anomalous pulmonary venous connection (8.60%), and Blalock Taussig shunts (7.53%) predominantly. There was no COVID-19-related mortality and none of the health-care workers developed COVID-19 in the entire study period.
Conclusions The initial phase of resource conservation has undermined the routine cardiac surgical practice. The study showed that strict adherence to management algorithm is necessary for persisting smooth continuation of cardiac surgical practice with provision of optimum critical care. The strategic comeback against COVID-19 would urge institutional development of protocols to aid the post-surge period.
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Affiliation(s)
- Manoj Kumar Sahu
- Intensive Care for Cardiothoracic and Vascular Surgery, CT Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Prateek Vaswani
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Amitabh Satsangi
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sarvesh Pal Singh
- Intensive Care for Cardiothoracic and Vascular Surgery, CT Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Palleti Rajashekar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Velayoudam Devagourou
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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21
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Abstract
PURPOSE OF REVIEW To review the current state of preoperative psychological preparation to improve outcomes after cardiac surgery. RECENT FINDINGS Preoperative psychosocial factors are associated with short- and long-term outcomes after cardiac surgery. There are several approaches to optimize patients' preoperative psychological status with promising effects on postoperative outcomes (e.g., less complications, improved quality of life). Preoperative psychological preparation often aims to improve patients' knowledge or social support and to modify and optimize expectations and illness beliefs. Preoperative psychological preparation is gaining importance for cardiac surgery. However, patients' psychological status still does not get as much attention as it deserves. Preoperative psychological preparation seems to have positive effects on postoperative outcomes. Since overall evidence is still weak, further studies are warranted to understand which intervention works best for whom and why.
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Affiliation(s)
- Stefan Salzmann
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | | | - Marcel Wilhelm
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
| | - Frank Euteneuer
- Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032 Marburg, Germany
- Department of Psychology, Clinical Psychology and Psychotherapy, Medical School Berlin, Berlin, Germany
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22
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Gahl B, Çelik M, Head SJ, Vanoverschelde JL, Pibarot P, Reardon MJ, van Mieghem NM, Kappetein AP, Jüni P, da Costa BR. Natural History of Asymptomatic Severe Aortic Stenosis and the Association of Early Intervention With Outcomes: A Systematic Review and Meta-analysis. JAMA Cardiol 2020; 5:1102-1112. [PMID: 32639521 DOI: 10.1001/jamacardio.2020.2497] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Whether intervention should be performed in patients with asymptomatic severe aortic stenosis (AS) remains debated. Objective To meta-analyze the natural history of asymptomatic severe AS and examine the association of early intervention with survival. Data Sources PubMed, Embase, and Cochrane databases were searched from inception to February 1, 2020. Study Selection Observational studies of adult patients with asymptomatic severe AS. Data Extraction and Synthesis Two investigators independently extracted study and patient characteristics, follow-up time, events, and prognostic indicators of events. Random-effects models were used to derive pooled estimates. Main Outcomes and Measures The meta-analysis on natural history was performed on the primary end point of all-cause death occurring during a conservative treatment period, with secondary end points consisting of cardiac death, death due to heart failure, sudden death, development of symptoms, development of an indication for aortic valve intervention, and aortic valve intervention. The primary end point for the meta-analysis of early intervention vs a conservative strategy was all-cause death during long-term follow-up. Finally, meta-analysis was performed on the association of prognostic indicators with the composite of death or aortic valve intervention found in multivariable models. Results A total of 29 studies with 4075 patients with 11 901 years of follow-up were included. Pooled rates per 100 patients per year were 4.8 (95% CI, 3.6-6.4) for all-cause death, 3.0 (95% CI, 2.2-4.1) for cardiac death, 2.0 (95% CI, 1.3-3.1) for death due to heart failure, 1.1 (95% CI, 0.6-2.1) for sudden death, 18.1 (95% CI, 12.8-25.4) for an indication for aortic valve intervention, 18.5 (95% CI, 13.4-25.5) for development of symptoms, and 19.2 (95% CI, 15.5-23.8) for aortic valve intervention. Early intervention was associated with a significant reduction in long-term mortality (hazard ratio, 0.38; 95% CI, 0.25-0.58). Factors associated with worse prognosis were severity of AS, low-flow AS, left ventricular damage, and atherosclerotic risk factors. Conclusions and Relevance Data from observational studies and a recent randomized clinical trial suggest that many patients with asymptomatic severe AS develop an indication for aortic valve intervention, and their deaths are mostly cardiac but not only sudden. Other end points besides sudden death should be considered during the decision to perform early intervention that are associated with improved survival.
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Affiliation(s)
- Brigitta Gahl
- Clinical Trial Unit Bern, University of Bern, Bern, Switzerland
| | - Mevlüt Çelik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.,Medtronic, Maastricht, the Netherlands
| | - Jean-Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Michael J Reardon
- Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bruno R da Costa
- Institute of Health Policy, Management and Evaluation, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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23
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Shehata IM, Elhassan A, Jung JW, Urits I, Viswanath O, Kaye AD. Elective cardiac surgery during the COVID-19 pandemic: Proceed or postpone? Best Pract Res Clin Anaesthesiol 2020; 34:643-650. [PMID: 33004173 PMCID: PMC7368150 DOI: 10.1016/j.bpa.2020.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 01/01/2023]
Abstract
During this coronavirus disease 2019 (COVID-19) pandemic, there is an international call to postpone all elective surgeries. Cardiac surgery carries a combined risk for cardiac patients, who are at risk for higher complications of COVID-19, and healthcare workers. In response to the COVID-19 pandemic, the American College of Surgeons and the American Society of Anesthesiologists recommended a sustained reduction in the rate of new COVID-19 cases for 14 days before the resumption of the elective surgery, but postponing surgery may impact patients' daily activities and increase the risk the of deterioration of their cardiac condition. We will discuss the risks and benefits of the decision whether to postpone or proceed with elective cardiac surgical procedures during the escalating COVID-19 pandemic considering the specific risk of the cardiac patients, the unique characteristics of the surgery, and the international health system capacity.
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Affiliation(s)
- Islam M Shehata
- Ain Shams Hospital, Department of Anesthesiology, Cairo, Egypt
| | - Amir Elhassan
- Desert Regional Medical Center, Cardiothoracic Anesthesia, Palm Springs, CA, USA
| | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Omar Viswanath
- Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
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24
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Bakaeen FG, Gillinov AM, Roselli EE, Chikwe J, Moon MR, Adams DH, Coselli JS, Dearani JA, Svensson LG. Cardiac surgery and the coronavirus disease 2019 pandemic: What we know, what we do not know, and what we need to do. J Thorac Cardiovasc Surg 2020; 160:722-726. [PMID: 32467022 PMCID: PMC7200351 DOI: 10.1016/j.jtcvs.2020.04.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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25
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Reply: A problem of "ethic" proportions. J Thorac Cardiovasc Surg 2020; 161:e233-e234. [PMID: 32792148 PMCID: PMC7417963 DOI: 10.1016/j.jtcvs.2020.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
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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: 4027] [Impact Index Per Article: 1006.8] [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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Ren YS, Li LF, Peng T, Tan YJ, Sun Y, Cheng GL, Zhang GM, Li J. The effect of milrinone on mortality in adult patients who underwent CABG surgery: a systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis. BMC Cardiovasc Disord 2020; 20:328. [PMID: 32640988 PMCID: PMC7346403 DOI: 10.1186/s12872-020-01598-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery. Methods We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration. Results The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences. Conclusions Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.
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Affiliation(s)
- Yu-Shan Ren
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Lan-Fang Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Tao Peng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Yu-Jun Tan
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Ying Sun
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Guo-Liang Cheng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Gui-Min Zhang
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Jie Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China. .,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China. .,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.
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29
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Spahn DR, Schoenrath F, Spahn GH, Seifert B, Stein P, Theusinger OM, Kaserer A, Hegemann I, Hofmann A, Maisano F, Falk V. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet 2019; 393:2201-2212. [PMID: 31036337 DOI: 10.1016/s0140-6736(18)32555-8] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. This study assessed whether immediate preoperative treatment could result in reduced perioperative red blood cell (RBC) transfusions and improved outcome. METHODS In this single-centre, randomised, double-blind, parallel-group controlled study, patients undergoing elective cardiac surgery with anaemia (n=253; haemoglobin concentration (Hb) <120 g/L in women and Hb <130 g/L in men) or isolated iron deficiency (n=252; ferritin <100 mcg/L, no anaemia) were enrolled. Participants were randomly assigned (1:1) with the use of a computer-generated range minimisation (allocation probability 0·8) to receive either placebo or combination treatment consisting of a slow infusion of 20 mg/kg ferric carboxymaltose, 40 000 U subcutaneous erythropoietin alpha, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid or placebo on the day before surgery. Primary outcome was the number of RBC transfusions during the first 7 days. This trial is registered with ClinicalTrials.gov, number NCT02031289. FINDINGS Between Jan 9, 2014, and July 19, 2017, 1006 patients were enrolled; 505 with anaemia or isolated iron deficiency and 501 in the registry. The combination treatment significantly reduced RBC transfusions from a median of one unit in the placebo group (IQR 0-3) to zero units in the treatment group (0-2, during the first 7 days (odds ratio 0·70 [95% CI 0·50-0·98] for each threshold of number of RBC transfusions, p=0·036) and until postoperative day 90 (p=0·018). Despite fewer RBC units transfused, patients in the treatment group had a higher haemoglobin concentration, higher reticulocyte count, and a higher reticulocyte haemoglobin content during the first 7 days (p≤0·001). Combined allogeneic transfusions were less in the treatment group (0 [IQR 0-2]) versus the placebo group (1 [0-3]) during the first 7 days (p=0·038) and until postoperative day 90 (p=0·019). 73 (30%) serious adverse events were reported in the treatment group group versus 79 (33%) in the placebo group. INTERPRETATION An ultra-short-term combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid reduced RBC and total allogeneic blood product transfusions in patients with preoperative anaemia or isolated iron deficiency undergoing elective cardiac surgery. FUNDING Vifor Pharma and Swiss Foundation for Anaesthesia Research.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, partner site Berlin, Germany
| | - Gabriela H Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Oliver M Theusinger
- Department of Anaesthesiology, University of Zurich and University Hospital Balgrist, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Inga Hegemann
- Division of Haematology, University of Zurich and Zurich University Hospital, Zurich, Switzerland
| | - Axel Hofmann
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland; School of Surgery, University of Western Australia and School of Public Health Research, Curtin University, Perth, Western Australia, Australia
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Berlin, Germany; Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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30
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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: 310] [Impact Index Per Article: 62.0] [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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31
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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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Gestion des agents antiplaquettaires pour une procédure invasive programmée. Propositions du Groupe d’intérêt en hémostase périopératoire (GIHP) et du Groupe français d’études sur l’hémostase et la thrombose (GFHT) en collaboration avec la Société française d’anesthésie-réanimation (SFAR). ANESTHÉSIE & RÉANIMATION 2018. [DOI: 10.1016/j.anrea.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Morgan D, Ho K, Kolybaba M, Ong Y. Punctuality is the duty of subjects and the politeness of monarchs. Response to Br J Anaesth 2018; 121: 982–3. Br J Anaesth 2018; 121:983-984. [DOI: 10.1016/j.bja.2018.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022] Open
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34
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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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