1
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Sibilitz KL, Tang LH, Berg SK, Thygesen LC, Risom SS, Rasmussen TB, Schmid JP, Borregaard B, Hassager C, Køber L, Taylor RS, Zwisler AD. Long-term effects of cardiac rehabilitation after heart valve surgery - results from the randomised CopenHeart VR trial. SCAND CARDIOVASC J 2022; 56:247-255. [PMID: 35811477 DOI: 10.1080/14017431.2022.2095432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/15/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
Aims. The CopenHeartVR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeartVR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol. Methods. A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test. Results. No differences in VO2 peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p = .03), and 12 (53% vs 67%, p = .04) months, respectively, but no significant effect at 24 months. Conclusions. Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.
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Affiliation(s)
- Kirstine L Sibilitz
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Hermann Tang
- REHPA - The Danish Knowledge Centre for Rehabilitation and Palliative Care and University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Selina Kikkenborg Berg
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Signe Stelling Risom
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute for Nursing and Nutrition, University College Copenhagen, Tagensvej, Denmark
| | - Trine Bernholdt Rasmussen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Jean-Paul Schmid
- Swiss Cardiovascular Centre Bern, Cardiovascular Prevention and Rehabilitation Unit, University Hospital, Bern, Switzerland
| | - Britt Borregaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rod S Taylor
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Ann-Dorthe Zwisler
- REHPA - The Danish Knowledge Centre for Rehabilitation and Palliative Care and University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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2
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Chambers JB. Specialists give better care than generalists for mitral valve disease. Eur J Cardiothorac Surg 2021; 60:274-275. [PMID: 34021324 DOI: 10.1093/ejcts/ezab103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
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3
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Sardari Nia P, Olsthoorn JR, Heuts S, van Kuijk SMJ, Vainer J, Streukens S, Schalla S, Segers P, Barenbrug P, Crijns HJGM, Maessen JG. Effect of a dedicated mitral heart team compared to a general heart team on survival: a retrospective, comparative, non-randomized interventional cohort study based on prospectively registered data. Eur J Cardiothorac Surg 2021; 60:263-273. [PMID: 33783480 DOI: 10.1093/ejcts/ezab065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/21/2020] [Accepted: 01/13/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Although in both the US and European guidelines the 'heart team approach' is a class I recommendation, supporting evidence is still lacking. Therefore, we sought to provide comparative survival data of patients with mitral valve disease referred to the general and the dedicated heart team. METHODS In this retrospective cohort, patients evaluated for mitral valve disease by a general heart team (2009-2014) and a dedicated mitral valve heart team (2014-2018) were included. Decision-making was recorded prospectively in heart team electronic forms. The end point was overall survival from decision of the heart team. RESULTS In total, 1145 patients were included of whom 641 (56%) were discussed by dedicated heart team and 504 (44%) by general heart team. At 5 years, survival probability was 0.74 [95% confidence interval (CI) 0.68-0.79] for the dedicated heart team group compared to 0.70 (95% CI 0.66-0.74, P = 0.040) for the general heart team. Relative risk of mortality adjusted for EuroSCORE II, treatment groups (surgical, transcatheter and non-intervention), mitral valve pathology (degenerative, functional, rheumatic and others) and 13 other baseline characteristics for patients in the dedicated heart team was 29% lower [hazard ratio (HR) 0.71, 95% CI 0.54-0.95; P = 0.019] than for the general heart team. The adjusted relative risk of mortality was 61% lower for patients following the advice of the heart team (HR 0.39, 95% CI 0.25-0.62; P < 0.001) and 43% lower for patients following the advice of the general heart team (HR 0.57, 95% CI 0.37-0.87; P = 0.010) compared to those who did not follow the advice of the heart team. CONCLUSIONS In this retrospective cohort, patients treated for mitral valve disease based on a dedicated heart team decision have significantly higher survival independent of the allocated treatment, mitral valve pathology and baseline characteristics.
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Affiliation(s)
- Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
| | - Jindrich Vainer
- Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Sebastian Streukens
- Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Patrique Segers
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
| | - Paul Barenbrug
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands
| | - Harry J G M Crijns
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, Netherlands
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4
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Trauzeddel RF, Nordine M, Balanika M, Bence J, Bouchez S, Ender J, Erb JM, Fassl J, Fletcher N, Mukherjee C, Prabhu M, van der Maaten J, Wouters P, Guarracino F, Treskatsch S. Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe: Results of an Online Survey. J Cardiothorac Vasc Anesth 2020; 35:1737-1746. [PMID: 33036889 DOI: 10.1053/j.jvca.2020.09.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. DESIGN Structured web-based, anonymized, voluntary survey. SETTING Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. PARTICIPANTS Physicians. MEASUREMENTS AND MAIN RESULTS The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. CONCLUSION The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.
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Affiliation(s)
- Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Nordine
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marina Balanika
- Department of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Johan Bence
- Department of Anaesthesia and Intensive Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University, Gent, Belgium
| | - Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Leipzig Heart Center, Leipzig, Germany
| | | | - Jens Fassl
- Institute of Cardiac Anesthesiology, University Heart Center Dresden, Dresden, Germany
| | - Nick Fletcher
- St Georges Hospital NHS Trust, London, United Kingdom; Cleveland Clinic, London, United Kingdom
| | - Chirojit Mukherjee
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Heart Surgery Clinic Karlsruhe, Karlsruhe, Germany
| | - Mahesh Prabhu
- Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Joost van der Maaten
- Department of Anesthesiology, University Medical Center Groningen, Faculty of Medical Sciences, Groningen, The Netherlands
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University, Gent, Belgium
| | - Fabio Guarracino
- Department of Anesthesiology and Critical Care Medicine, Azienda Ospedaliero-Universitatria Pisana, Pisa, Italy
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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5
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Donal E, Galli E, Anselmi A, Bidaut A, Leurent G. EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: The central role of the cardiac imager in heart valve disease. Echo Res Pract 2019; 6:T15-T21. [PMID: 31729211 PMCID: PMC6865361 DOI: 10.1530/erp-19-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In this review, we discuss the central role of the imager in the heart team in the successful application of current guidelines for heart valve diseases to daily practice, and for improving patient care through new approaches, new techniques and new strategies for dealing with increasingly complex cases. This is an opportunity to emphasize the importance of having good imagers and the value of continuous learning in a modern heart team. It is essential to employ technological improvements and to appropriately adapt guidelines to the patients we see day to day.
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Affiliation(s)
- Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Elena Galli
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Amedeo Anselmi
- The Cardio Vascular Surgical Department, University of Rennes, CHU Rennes, Rennes, France
| | - Auriane Bidaut
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Guillaume Leurent
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
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6
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Borregaard B, Møller JE, Dahl JS, Riber LPS, Berg SK, Ekholm O, Weiss MG, Lykking EK, Sibilitz KL, Sørensen J. Early follow-up after open heart valve surgery reduces healthcare costs: a propensity matched study. Open Heart 2019; 6:e001122. [PMID: 31798915 PMCID: PMC6861062 DOI: 10.1136/openhrt-2019-001122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/15/2019] [Accepted: 10/30/2019] [Indexed: 12/27/2022] Open
Abstract
Objectives The objective was to assess differences in healthcare costs within 180 days after discharge from open heart valve surgery in an intervention group receiving early, individualised and intensified follow-up compared with a historical control group. Methods A cost-minimisation analysis comparing costs from a consecutive prospective cohort compared with a propensity matched cohort. Costs related to the intervention, hospital (outpatient visits and readmissions) and general practitioners (all contacts) were included. Data were obtained from electronic patient records and registry data. A logistic propensity model was used to identify the historical control group. Main results are presented as mean differences and 95% CIs based on bootstrapping. Results After matching, the analysis included 300 patients from the intervention group and 580 controls. The mean intervention cost was €171 (SD 79) per patient. After 180 days, the mean healthcare costs were €1284 (SD 2567) for the intervention group and €2077 (SD 4773) for the controls. The cost of the intervention group was €793 (p<0.001) less per patient. The cost differences were explained mainly by fewer readmissions, fewer overall emergency visits and fewer contacts to the general practitioner during out-of-hours in the intervention group. Conclusions The intervention consisting of early, individualised and intensified follow-up after open heart valve surgery significantly reduced the healthcare costs within 180 days after discharge.
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Affiliation(s)
- Britt Borregaard
- Department of Cardiothoracic and Vascular Surgery, Odense Universitetshospital, Odense, Denmark.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Open Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Jacob Eifer Møller
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Odense Universitetshospital, Odense, Denmark
| | - Jordi Sanchez Dahl
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Odense Universitetshospital, Odense, Denmark
| | - Lars Peter Schødt Riber
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Thoracic Surgery, Odense Universitetshospital, Odense, Denmark
| | - Selina Kikkenborg Berg
- Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicin, University of Copenhagen, Copenhagen, Denmark
| | - Ola Ekholm
- National Institute of Public Health, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Marc Gjern Weiss
- Department of Cardiothoracic and Vascular Surgery, Odense Universitetshospital, Odense, Denmark
| | - Emilie Karense Lykking
- Department of Cardiothoracic and Vascular Surgery, Odense Universitetshospital, Odense, Denmark
| | - Kirstine Lærum Sibilitz
- Centre for Cardiac, Vascular, Pulmonary and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Jan Sørensen
- Healthcare Outcomes Research Centre (HORC), Royal College of Surgeons in Ireland Clinical Research Centre, Dublin, Ireland.,Centre for Health Economics Research (COHERE), National Institute of Public Health, University of Southern Denmark, Odense C, Denmark
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7
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Affiliation(s)
- Christopher R Burke
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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8
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Attias D, Nejjari M, Nappi F, Dreyfus J, Eleid MF, Rihal CS. How to treat severe symptomatic structural valve deterioration of aortic surgical bioprosthesis: transcatheter valve-in-valve implantation or redo valve surgery? Eur J Cardiothorac Surg 2019; 54:977-985. [PMID: 29868728 DOI: 10.1093/ejcts/ezy204] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/22/2018] [Indexed: 11/12/2022] Open
Abstract
The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.
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Affiliation(s)
- David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Mohammed Nejjari
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint Denis, France
| | - Julien Dreyfus
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Mackram F Eleid
- Department of Cardiovascular Diseases and Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases and Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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