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Núñez-Gil IJ, Rodríguez-Caulo EA, García-Cosío MD, Piñón M, Díez-Del Hoyo F, Eixerés A, Carrasco-Chinchilla F, López-Menéndez J, Pérez-Villacastín J, Rodríguez-Roda J. Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00161-0. [PMID: 38797501 DOI: 10.1016/j.rec.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/18/2024] [Indexed: 05/29/2024]
Abstract
In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals' opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.
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Affiliation(s)
- Iván J Núñez-Gil
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Madrid, Spain.
| | - Emiliano A Rodríguez-Caulo
- Servicio de Cirugía Cardiovascular, Área del Corazón, Hospital Universitario Virgen Macarena, Seville, Spain
| | - M Dolores García-Cosío
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Miguel Piñón
- Servicio de Cirugía Cardiovascular, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Felipe Díez-Del Hoyo
- Unidad de Cardiología Intervencionista, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Andrea Eixerés
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Fernando Carrasco-Chinchilla
- Servicio de Cardiología, Hospital Virgen de la Victoria, Instituto de investigación Biomédica Málaga (IBIMA), Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - José López-Menéndez
- Servicio de Cirugía Cardiovascular, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Julián Pérez-Villacastín
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Jorge Rodríguez-Roda
- Servicio de Cirugía Cardiovascular, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Vervoort D, Sud M, Zeis TM, Haouzi AA, An KR, Rocha R, Eikelboom R, Fremes SE, Tamis-Holland JE. Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines. Can J Cardiol 2024; 40:275-289. [PMID: 38181974 DOI: 10.1016/j.cjca.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tessa M Zeis
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alice A Haouzi
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Eikelboom
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Mazza A, Iafrancesco M, Bruno P, Chiariello GA, Trani C, Burzotta F, Cammertoni F, Pasquini A, Diana G, Rosenhek R, Liuzzo G, Rabini A, Flex A, Raweh A, Crea F, Massetti M. The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine. J Cardiovasc Med (Hagerstown) 2023; 24:906-913. [PMID: 37577876 DOI: 10.2459/jcm.0000000000001511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
AIMS Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients. METHODS In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients. RESULTS Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P < 0.001, G1 vs. G3: P = 0.01, G2 vs. G3: P = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%. CONCLUSION Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the decision-making process and clinical results.
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Affiliation(s)
- Andrea Mazza
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Mauro Iafrancesco
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Piergiorgio Bruno
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Giovanni Alfonso Chiariello
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Carlo Trani
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Francesco Burzotta
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Federico Cammertoni
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Annalisa Pasquini
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Giovanni Diana
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Raphael Rosenhek
- Catholic University of The Sacred Heart, Rome, Italy
- Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Giovanna Liuzzo
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Alessia Rabini
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Andrea Flex
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Abdallah Raweh
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Filippo Crea
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Massetti
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS
- Catholic University of The Sacred Heart, Rome, Italy
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Ram E, Kassif T, Peled Y, Kassif Y, Koren RP, Sternik L, Raanani E. Anatomical and clinical risk stratification tool for mortality risk assessment following revascularization for multivessel coronary artery disease. J Thorac Cardiovasc Surg 2023; 166:793-800.e5. [PMID: 35031136 DOI: 10.1016/j.jtcvs.2021.11.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/24/2021] [Accepted: 11/23/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to assess the prognostic ability of SYNTAX score II in left main and/or 3-vessel disease patients undergoing revascularization either by coronary artery bypass grafting or percutaneous coronary intervention in a national registry. METHODS This prospective registry included consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography. Of the 1112 study patients, 368 patients (33%) had a low (<25), 372 (33%) had an intermediate (25-35) and 372 patients (33%) a high (≥35) SYNTAX score II. RESULTS Patients with a high SYNTAX score II had higher 30-day mortality compared with those with an intermediate or low SYNTAX score II (2.8% vs 0.6% vs 0% respectively, P = .001). Each 1-unit increment in SYNTAX score II increased the odds for death at 30 days by 11% (95% CI, 1.02-1.22; P = .026). Six-year mortality was higher among patients with a high compared with an intermediate or low SYNTAX score II (34.9% vs 11% vs 3.8%; log-rank P < .001). By adding a SYNTAX score II to standard prognostic factors, we showed a significant improvement of 40.1% (P < .001) for predicting 6-year mortality. The area under the curve of the SYNTAX score II (continuous) yielded 0.79 (95% CI, 0.75-0.82) in predicting 6-year mortality. CONCLUSIONS Our findings show that the admission SYNTAX score II is a powerful marker of short- and long-term mortality, and therefore may be used as a risk stratification tool in patients with multivessel coronary artery disease who are candidates for revascularization.
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Affiliation(s)
- Eilon Ram
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel; The Sheba Talpiot Medical Leadership Program, Ramat Gan, Israel.
| | - Tohar Kassif
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Yael Peled
- Department of Cardiology, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Yigal Kassif
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Roni Postan Koren
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
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Hasan SU, Pervez A, Naseeb MW, Rajput BS, Faheem A, Hameed I, Sá MP, Zubair MM. Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis. Perfusion 2023:2676591231182585. [PMID: 37294619 DOI: 10.1177/02676591231182585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD. METHODS A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries. RESULTS A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes. CONCLUSIONS ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.
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Affiliation(s)
| | | | | | | | - Ariba Faheem
- Dow University of Health Sciences, Karachi, Pakistan
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Wynnewood, PA, USA
| | - M Mujeeb Zubair
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Ma H, Lin S, Li X, Wang Y, Xu B, Zheng Z. Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases. BMJ Open 2022; 12:e064761. [PMID: 36456006 PMCID: PMC9716884 DOI: 10.1136/bmjopen-2022-064761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD). METHODS AND ANALYSIS Eighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry. TRIAL REGISTRATION NUMBER NCT05039567.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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Ram E, Fisman EZ, Tenenbaum A, Iakobishvili Z, Peled Y, Raanani E, Sternik L. Revascularization outcomes in diabetic patients presenting with acute coronary syndrome with non-ST elevation. Cardiovasc Diabetol 2022; 21:175. [PMID: 36064537 PMCID: PMC9443038 DOI: 10.1186/s12933-022-01595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
Background To compare the outcomes of diabetic patients hospitalized with non-ST elevation myocardial infarction (NSTEMI) or unstable angina (UA) referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-life setting. Methods The study included 1987 patients with diabetes mellitus enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for NSTEMI or UA, and underwent either PCI (N = 1652, 83%) or CABG (N = 335, 17%). Propensity score-matching analysis compared all-cause mortality in 200 pairs (1:1) who underwent revascularization by either PCI or CABG. Results Independent predictors for CABG referral included 3-vessel coronary artery disease (OR 4.9, 95% CI 3.6–6.8, p < 0.001), absence of on-site cardiac surgery (OR 1.4, 95% CI 1.1–1.9, p = 0.013), no previous PCI (OR 1.5, 95% CI 1.1–2.2, p = 0.024) or MI (OR 1.7, 95% CI 1.2–2.6, p = 0.002). While at 2 years of follow-up, survival analysis revealed no differences in mortality risk between the surgical and percutaneous revascularization groups (log-rank p = 0.996), after 2 years CABG was associated with a significant survival benefit (HR 1.53, 95% CI 1.07–2.21; p = 0.021). Comparison of the propensity score matching pairs also revealed a consistent long-term advantage toward CABG (log-rank p = 0.031). Conclusions In a real-life setting, revascularization by CABG of diabetic patients hospitalized with NSTEMI/UA is associated with better long-term outcomes. Prospective randomized studies are warranted in order to provide more effective recommendations in future guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01595-5.
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Affiliation(s)
- Eilon Ram
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel. .,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel. .,The Sheba Talpiot Medical Leadership Program, Ramat Gan, Israel. .,Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, 52621, Ramat Gan, Israel.
| | - Enrique Z Fisman
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Alexander Tenenbaum
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Zaza Iakobishvili
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel.,Clalit Health Services, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Department of Cardiology, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Tel Aviv University, Tel Aviv, Israel.,Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
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Klein LW, Abugroun A, Daoud H. Rates of revascularization and PCI:CABG ratio: a new indicator predicting in-hospital mortality in acute coronary syndromes. Coron Artery Dis 2022; 33:69-74. [PMID: 34074913 DOI: 10.1097/mca.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality. METHODS The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality. RESULTS Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality. CONCLUSIONS The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.
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Affiliation(s)
- Lloyd W Klein
- Cardiology Section, University of California San Francisco, San Francisco, California
| | | | - Hussein Daoud
- Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
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Senman B, Rao SV. Heart Team Without Borders: Taking the Heart Team Beyond the Institution. J Am Heart Assoc 2022; 11:e025080. [PMID: 35225005 PMCID: PMC9075071 DOI: 10.1161/jaha.122.025080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Sunil V. Rao
- Duke University Health System Durham NC
- The Duke Clinical Research Institute Durham NC
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Ma H, Lin S, Li X, Dou K, Yang W, Feng W, Liu S, Wu Y, Peng B, Zheng Z. Exploring optimal heart team protocol to improve decision-making stability for complex coronary artery disease: a sequential explanatory mixed method study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:739-749. [PMID: 34634101 DOI: 10.1093/ehjqcco/qcab074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022]
Abstract
AIMS Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. METHODS AND RESULTS This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. CONCLUSIONS Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kefei Dou
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Weixian Yang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Feng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Wu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Boshizhang Peng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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11
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Cormican DS, Drennen Z, Sonny A, Crowley JC, Gil IJN, Ramakrishna H. Functional Mitral Regurgitation in Heart Failure: Analysis of the ESC Multidisciplinary Heart-Team Position Statement and Review of Current Guidelines. J Cardiothorac Vasc Anesth 2021; 36:3357-3364. [PMID: 34607763 DOI: 10.1053/j.jvca.2021.09.004] [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] [Received: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel S Cormican
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Zachary Drennen
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Abraham Sonny
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Jerome C Crowley
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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12
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Witberg G, Segev A, Barac YD, Raanani E, Assali A, Finkelstein A, Roguin A, Sahar G, Vaknin-Assa H, Bolotin G, Eitan A, Klempfner R, Goldenberg I, Kornowski R. Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease. Circ Cardiovasc Interv 2021; 14:e009686. [PMID: 33423541 DOI: 10.1161/circinterventions.120.009686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. METHODS This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. RESULTS Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. CONCLUSIONS Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.
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Affiliation(s)
- Guy Witberg
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Amit Segev
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Yaron D Barac
- Department of Cardiovascular and Thoracic Surgery (Y.D.B.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Ehud Raanani
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Abid Assali
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Department of Cardiology, Meir Medical Center, Kfar-Saba, Israel (A.A.)
| | - Ariel Finkelstein
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Department of Cardiology, Tel Aviv Medical Center, Israel (A.F.)
| | - Ariel Roguin
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel (A.R.)
| | - Gideon Sahar
- Department of Cardiac Surgery, Soroka Medical Center, Be'er-Sheva, Israel (G.S.).,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel (G.S.)
| | - Hana Vaknin-Assa
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
| | - Gil Bolotin
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiothoracic surgery, Rambam Health Care Campus, Haifa, Israel (G.B.)
| | - Amnon Eitan
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa (A.R., G.B., A.E.).,Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel (A.E.)
| | - Robert Klempfner
- Department of Cardiology (G.W., H.V.-A., R.K.), Rabin Medical Center, Petach-Tikva, Israel.,Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Ilan Goldenberg
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.).,Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel (A.S., E.R., R.K., I.G.)
| | - Ran Kornowski
- Sackler school of Medicine, Tel-Aviv University, Israel (G.W., A.S., Y.D.B., E.R., A.A., A.F., H.V.-A., R.K., I.G., R.K.)
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13
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Tsang MB, Schwalm JD, Gandhi S, Sibbald MG, Gafni A, Mercuri M, Salehian O, Lamy A, Pericak D, Jolly S, Sheth T, Ainsworth C, Velianou J, Valettas N, Mehta S, Pinilla N, Yanagawa B, Zhang L, Chu V, Parry D, Whitlock R, Dyub A, Cybulsky I, Semelhago L, Ioannou K, Hameed A, Wright D, Mulji A, Darvish-Kazem S, Gupta N, Alshatti A, Natarajan MK. Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e2012749. [PMID: 32777060 PMCID: PMC7417969 DOI: 10.1001/jamanetworkopen.2020.12749] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. OBJECTIVE To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. MAIN OUTCOMES AND MEASURES The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. RESULTS Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). CONCLUSIONS AND RELEVANCE The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.
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Affiliation(s)
- Michael B. Tsang
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J. D. Schwalm
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sumeet Gandhi
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Matthew G. Sibbald
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Center for Health Economics and Policy Analysis, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dan Pericak
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sanjit Jolly
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tej Sheth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Velianou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Valettas
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shamir Mehta
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Natalia Pinilla
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Li Zhang
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Victor Chu
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Parry
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Dunedin Hospital, Otago, New Zealand
| | - Richard Whitlock
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Adel Dyub
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Irene Cybulsky
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lloyd Semelhago
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kostas Ioannou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Adnan Hameed
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Douglas Wright
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amin Mulji
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Saeed Darvish-Kazem
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Brampton Civic Hospital, William Osler Health System, Brampton, Ontario, Canada
| | - Nandini Gupta
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Alshatti
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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14
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3841] [Impact Index Per Article: 960.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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15
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Midterm outcomes of patients with multivessel disease treated at centers with and without on-site cardiac surgery services. J Thorac Cardiovasc Surg 2020; 163:1852-1861.e3. [PMID: 32711976 DOI: 10.1016/j.jtcvs.2020.04.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The last decade has witnessed an increased number of stand-alone interventional cardiology units due to the consolidation of cardiac surgery services. We aimed to explore the impact of a heart team on the midterm outcomes of patients with multivessel coronary artery disease. METHODS This prospective registry included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention, with or without on-site cardiac surgery services. RESULTS Of the 1063 patients, 576 (54%) and 487 (46%) were admitted to centers with or without on-site cardiac surgery services, respectively. Centers with cardiac surgery services compared with those without had more male patients (82% vs 77%, P = .026) and more patients who were taking aspirin (75% vs 67%, P = .008) before admission. Other characteristics were similar between the groups, including mean SYNTAX score (22.5 ± 9.6 vs 22.2 ± 10, P = .680). Late outcomes revealed a higher 6-year survival probability in centers with on-site cardiac surgery services (85.1% vs 81.3%, P = .047). Although coronary artery bypass grafting (vs percutaneous coronary intervention) was associated with a survival advantage among patients from hospitals with cardiac surgery services (89.9% vs 81.5%, P = .004), in the absence of on-site cardiac surgery services there were no differences between the 2 revascularization approaches (81.8% vs 81.1%, P = .9). CONCLUSIONS Patients with multivessel coronary artery disease treated in centers without on-site cardiac surgery services receive a lower rate of appropriate guideline-based intervention with coronary artery bypass grafting, which is associated with less favorable outcomes. These findings suggest that a heart-team approach should be mandatory even in centers with stand-alone interventional cardiology units.
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16
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Exploring Current Evidence on the Past, the Present, and the Future of the Heart Team: A Narrative Review. Cardiovasc Ther 2020; 2020:9241081. [PMID: 31969934 PMCID: PMC6964708 DOI: 10.1155/2020/9241081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Including healthcare professionals dealing with cardiovascular diseases, Heart Team is a concept/structure designed for selecting diagnostic strategies, facilitating therapeutic decisions, and improving cardiovascular outcomes in patients with complex heart pathologies, requiring input from different subspecialties and the necessity of a multidisciplinary approach. The aim of this narrative review is to search for and to summarize current evidence regarding Heart Team and to underline the future directions for the development of this concept. Methods We searched the electronic database of PubMed, SCOPUS, and Cochrane CENTRAL for studies including Heart Team. Forty-eight studies were included, if reference was made to Heart Team structure and functionality. Results We depicted the structure and the timeline of Heart Team, along with actual evidence-based recommendations from European Guidelines. We underlined the importance of quality of knowledge-sharing and decision-making inside the Team, analyzing bad decisions which did not reflect members' true beliefs due to "uniformity pressure, closed mindedness, and illusion of invulnerability." The observation that Guidelines' indications regarding Heart Team carry a level C indication underlines the very future of this Team: randomized controlled trials proving solid benefits in an evidence-based world. Conclusions Envisioned as a tool for optimizing the management of various complex cardiovascular pathologies, Heart Team should simplify and facilitate the activity in the cardiovascular ward. Finally, these facts should be translated into better cardiovascular outcomes and a lower psychological distress among Team participants. Despite all future changes, there must always be a constant part: the patient should remain at the very center of the Team.
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17
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Impact of Hierarchy on Multidisciplinary Heart-Team Recommendations in Patients with Isolated Multivessel Coronary Artery Disease. J Clin Med 2019; 8:jcm8091490. [PMID: 31546762 PMCID: PMC6780608 DOI: 10.3390/jcm8091490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/17/2022] Open
Abstract
Background: The Heart Team (HT) discussion has been incorporated in the current guidelines for myocardial revascularization in order to optimize treatment decisions for patients with multivessel coronary disease (MVD). There are no data in the literature, whether hierarchical issues do have an impact on HT decisions. We aimed to analyze the therapeutic recommendations of the multidisciplinary "Heart Team" (HT) for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) if: (a) The head of cardiovascular surgery (HOS) and the head of cardiology (HOC) were present during the HT meeting, (b) both directors were absent, (c) only HOS or HOC was present. Methods: Retrospective analysis of all HT discussions between 2012 and 2015 in patients with isolated MVD (without any other cardiac problems requiring surgery). Results: During the study period, we analyzed 209 HT discussions in patients with isolated MVD. If neither HOS nor HOC was present at the HT discussion, the therapeutic recommendation was in 69% CABG and 31% PCI. If HOS and HOC were present in 77% CABG and 23% PCI was recommended (p = 0.34). If only HOS was present therapeutic recommendation was in 83% CABG and 17% PCI, and if only HOC was present the recommendation was in 54% CABG and 46% PCI (p < 0.0001). This difference did not attenuate during the study period. Conclusions: The hierarchy of the participating physicians significantly impacts treatment recommendations of a multidisciplinary HT in patients with isolated MVD. This impact did not attenuate after several years of Heart Team interaction.
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18
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 300] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Heuts S, Olsthoorn JR, Hermans SMM, Streukens SAF, Vainer J, Cheriex EC, Segers P, Maessen JG, Sardari Nia P. Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team. Neth Heart J 2019; 27:176-184. [PMID: 30742250 PMCID: PMC6439106 DOI: 10.1007/s12471-019-1238-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team. Methods All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team. Results One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%). Conclusion In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.
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Affiliation(s)
- S Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S M M Hermans
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S A F Streukens
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J Vainer
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - E C Cheriex
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P Segers
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - P Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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Domingues CT, Milojevic M, Thuijs DJFM, van Mieghem NM, Daemen J, van Domburg RT, Kappetein AP, Head SJ. Heart Team decision making and long-term outcomes for 1000 consecutive cases of coronary artery disease. Interact Cardiovasc Thorac Surg 2019; 28:206-213. [DOI: 10.1093/icvts/ivy237] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Carina T Domingues
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Netherlands
| | - Ron T van Domburg
- Department of Cardiology, Erasmus University Medical Center, Netherlands
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2018; 55:4-90. [PMID: 30165632 DOI: 10.1093/ejcts/ezy289] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Gripenberg T, Jokhaji F, Östlund-Papadogeorgos N, Ekenbäck C, Linder R, Samad B, Persson J. Outcome and selection of revascularization strategy in left main coronary artery stenosis. SCAND CARDIOVASC J 2018; 52:100-107. [PMID: 29357762 DOI: 10.1080/14017431.2018.1429648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy. DESIGN Consecutive patients with ULMCA stenosis at our institution in 2009-2013 (n = 308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression. RESULTS Patients that underwent PCI (n = 94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08-4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50-2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG. CONCLUSIONS In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.
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Affiliation(s)
- Thomas Gripenberg
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Fadi Jokhaji
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Nikolaos Östlund-Papadogeorgos
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Christina Ekenbäck
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Rikard Linder
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Bassem Samad
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
| | - Jonas Persson
- a Division of Cardiovascular Medicine, Department of Clinical Sciences , Karolinska Institutet, Danderyd University Hospital , Stockholm , Sweden
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Arri SS, Patterson T, Williams RP, Moschonas K, Young CP, Redwood SR. Myocardial revascularisation in high-risk subjects. Heart 2017; 104:166-179. [PMID: 29180542 DOI: 10.1136/heartjnl-2016-310487] [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: 11/04/2022] Open
Affiliation(s)
- Satpal S Arri
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Tiffany Patterson
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rupert P Williams
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Christopher P Young
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon R Redwood
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Pavlidis AN, Perera D, Karamasis GV, Bapat V, Young C, Clapp BR, Blauth C, Roxburgh J, Thomas MR, Redwood SR. Implementation and consistency of Heart Team decision-making in complex coronary revascularisation. Int J Cardiol 2016; 206:37-41. [DOI: 10.1016/j.ijcard.2016.01.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 11/04/2015] [Accepted: 01/01/2016] [Indexed: 12/31/2022]
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Bogers AJJC, Head SJ, Kappetein AP. What the cardiothoracic surgeon wants to know from the radiologist: from X-ray reporting to imaging consultancy and Heart Team membership. Pediatr Radiol 2015; 45:27-31. [PMID: 25552388 DOI: 10.1007/s00247-014-3151-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 07/07/2014] [Accepted: 08/06/2014] [Indexed: 12/24/2022]
Abstract
In the early days of cardiac surgery, the pretreatment multidisciplinary discussion involved a presentation of the case history and diagnostic imaging by the clinical cardiologist. At this time, most, if not all, cardiac imaging techniques were in the hands of the cardiologist. If the radiologist made a report, this was done relatively late in the clinical process and only concerned the perioperative radiographs. In recent years, multidisciplinary decision-making in the context of a Heart Team has gained an increasingly important role in the process of decision-making with regard to the available therapy options in individual patients. Nevertheless, the concept of the Heart Team is still evolving. The minimal requirements for the Heart Team include the presence of the attending cardiologist, an interventional cardiologist and a cardiac surgeon. Those members of the Heart Team should be aware of the local possibilities, should correctly make conclusions about the available data and should put this information into the clinical context and preference of the patient. In addition, in areas where expertise in cardiac imaging such as CT and MRI is relevant, this would explicitly require expertise of the Heart Team in these specific areas, most often by involving a radiologist, to provide the optimal joint treatment strategy recommendation.
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Affiliation(s)
- Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Thoraxcentre, Bd 557, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3291] [Impact Index Per Article: 329.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Differences in the outcome of patients undergoing percutaneous coronary interventions at teaching versus non-teaching hospitals. Am Heart J 2013; 166:401-8. [PMID: 24016486 DOI: 10.1016/j.ahj.2013.06.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 06/02/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Teaching hospitals have superior outcomes for major medical conditions including cardiovascular disease compared to non-teaching hospitals. This may not be applicable to invasive cardiac procedures given a potential increase in complications due to trainee participation. METHODS We assessed the impact of hospital teaching status on the outcome of 89,048 patients who underwent percutaneous coronary intervention (PCI). Teaching hospitals were defined as trainee involvement in greater than 50% of PCIs conducted at that hospital and corresponded to teaching status granted by national accreditation agencies. Unadjusted and risk adjusted analyses were used to determine differences in process of care, morbidity and mortality. RESULTS Of 89,048 patients studied, 30,870 received their PCI at teaching hospitals and 58,178 at non-teaching hospitals. Risk-adjusted analysis showed no significant difference in death, in-hospital myocardial infarction, contrast induced nephropathy or gastrointestinal bleeding between teaching and non-teaching hospitals. PCI at teaching hospitals was associated with a lower rate of emergency coronary artery bypass grafting (OR, 0.63; 95% CI, 0.49-0.83; P = .0009) and an increased rate of vascular complications (OR, 1.33; 95% CI, 1.21-1.46; P < .0001). CONCLUSIONS General outcomes of patients undergoing PCI are similar across hospital types. However, PCI at teaching hospitals is associated with increased risk of vascular complications and reduced risk of emergency coronary artery bypass grafting compared to non-teaching hospitals.
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Head SJ, Kaul S, Mack MJ, Serruys PW, Taggart DP, Holmes DR, Leon MB, Marco J, Bogers AJJC, Kappetein AP. The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease. Eur Heart J 2013; 34:2510-8. [PMID: 23425523 DOI: 10.1093/eurheartj/eht059] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Stable complex coronary artery disease can be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy. Multidisciplinary decision-making has gained more emphasis over the recent years to select the most optimal treatment strategy for individual patients with stable complex coronary artery disease. However, the so-called 'Heart Team' concept has not been widely implemented. Yet, decision-making has shown to remain suboptimal; there is large variability in PCI-to-CABG ratios, which may predominantly be the consequence of physician-related factors that have raised concerns regarding overuse, underuse, and inappropriate selection of revascularization. In this review, we summarize these and additional data to support the statement that a multidisciplinary Heart Team consisting of at least a clinical/non-invasive cardiologist, interventional cardiologist, and cardiac surgeon, can together better analyse and interpret the available diagnostic evidence, put into context the clinical condition of the patient as well as consider individual preference and local expertise, and through shared decision-making with the patient can arrive at a most optimal joint treatment strategy recommendation for patients with stable complex coronary artery disease. In addition, other aspects of Heart Team decision-making are discussed: the organization and logistics, involvement of physicians, patients, and assisting personnel, the need for validation, and its limitations.
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Abstract
BACKGROUND Physical therapists often prescribe exercises for fall prevention. Understanding the factors influencing the clinical decision-making processes used by expert physical therapists working in specialist fall and balance clinics may assist other therapists in prescribing exercises for fall prevention with greater efficacy. OBJECTIVES The objective of this study was to describe the factors influencing the clinical decision-making processes used by expert physical therapists to prescribe exercises for fall prevention. DESIGN This investigation was a qualitative study from a phenomenological perspective. METHODS Semistructured telephone interviews were conducted with 24 expert physical therapists recruited primarily from the Victorian Falls Clinic Coalition. Interviews focused on 3 exercise prescription contexts: face-to-face individual therapy, group exercise programs, and home exercise programs. Interviews elicited information about therapist practices and the therapist, patient, and environmental factors influencing the clinical decision-making processes for the selection of exercise setting, type, dosage (intensity, quantity, rest periods, duration, and frequency), and progression. Strategies for promoting adherence and safety were also discussed. Data were analyzed with a framework approach by 3 investigators. RESULTS Participants described highly individualized exercise prescription approaches tailored to address key findings from physical assessments. Dissonance between prescribing a program that was theoretically correct on the basis of physiological considerations and prescribing one that a client would adhere to was evident. Safety considerations also were highly influential on the exercise type and setting prescribed. Terminology for describing the intensity of balance exercises was vague relative to terminology for describing the intensity of strength exercises. CONCLUSIONS Physical therapists with expertise in fall prevention adopted an individualized approach to exercise prescription that was based on physical assessment findings rather than "off-the-shelf" exercise programs commonly used in fall prevention research. Training programs for people who prescribe exercises for older adults at risk of falling should encompass these findings.
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Tu JV, Ko DT, Guo H, Richards JA, Walton N, Natarajan MK, Wijeysundera HC, So D, Latter DA, Feindel CM, Kingsbury K, Cohen EA. Determinants of variations in coronary revascularization practices. CMAJ 2011; 184:179-86. [PMID: 22158396 DOI: 10.1503/cmaj.111072] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario. METHODS In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low-medium [2.0-2.7], medium-high [2.8-3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization. RESULTS The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%-99.0%) and those with left main artery disease usually underwent CABG (80.8%-94.2%), regardless of the hospital's procedure ratio. Variation in the management of patients with non-emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization "culture" at the treating hospital. INTERPRETATION The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non-emergent multivessel disease.
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Affiliation(s)
- Jack V Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ont.
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Hassan A, Newman A, Ko DT, Rinfret S, Hirsch G, Ghali WA, Tu JV. Increasing rates of angioplasty versus bypass surgery in Canada, 1994-2005. Am Heart J 2010; 160:958-65. [PMID: 21095286 DOI: 10.1016/j.ahj.2010.06.052] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 06/14/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is increasingly being offered to patients with coronary artery disease. The purpose of this study was to determine the impact of this change in coronary revascularization strategy on PCI and coronary artery bypass grafting (CABG) utilization across Canada. METHODS All cases of PCI and isolated CABG between years 1994 and 2005 were identified through the Canadian Institute for Health Information. Age- and sex-standardized rates of PCI and CABG per 100,000 population as well as PCI-to-CABG ratios were calculated by year and province and across age, sex, income, diabetes, and recent acute coronary syndrome subgroups. In addition, risk-adjusted rates of in-hospital mortality after PCI and CABG were reported by year. RESULTS Between 1994 and 2005, PCI rates increased from 85.6/100,000 to 186.7/100,000 (P < .001), whereas CABG rates remained stable (75.6/100,000-70.8/100,000; P = .43), resulting in an increase in PCI-to-CABG ratio (1.13-2.64; P < .001). Significant increases in PCI-to-CABG ratios were seen across all provinces (except Newfoundland and Alberta), as well as across all age, sex, income, diabetes, and recent acute coronary syndrome categories. Decline in risk-adjusted in-hospital mortality was seen after both CABG (3.9%-2.2%; P < .001) and PCI (1.6%-1.3%; P < .001) but appeared larger after CABG. CONCLUSIONS Since 1994, rates of PCI have increased significantly as compared to CABG. During the same period, greater declines in risk-adjusted rates of in-hospital mortality were seen among CABG versus PCI patients. Further study is needed to determine the appropriateness of PCI and CABG rates in terms of clinical outcomes and resource utilization.
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Affiliation(s)
- Ansar Hassan
- Department of Cardiac Surgery, New Brunswick Heart Center, Saint John, New Brunswick, Canada.
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Huesch MD. Provider-hospital "fit" and patient outcomes: evidence from Massachusetts cardiac surgeons, 2002-2004. Health Serv Res 2010; 46:1-26. [PMID: 20849555 DOI: 10.1111/j.1475-6773.2010.01169.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine whether the "fit" of a surgeon with hospital resources impacts cardiac surgery outcomes, separately from hospital or surgeon effects. DATA SOURCES Retrospective secondary data from the Massachusetts Department of Public Health's Data Analysis Center, on all 12,983 adult isolated coronary artery bypass surgical admissions in state-regulated hospitals from 2002 through 2004. Clinically audited chart data was collected using Society of Thoracic Surgeons National Cardiac Surgery Database tools and cross-referenced with administrative discharge data in the Division of Health Care Finance and Policy. Mortality was followed up through 2007 via the state vital statistics registry. STUDY DESIGN Analysis was at the patient level for those receiving isolated coronary artery bypass surgery (CABG). Sixteen outcomes included 30-day mortality, major morbidity, indicators of perioperative, and predischarge processes of care. Hierarchical crossed mixed models were used to estimate fixed covariate and random effects at hospital, surgeon, and hospital × surgeon level. PRINCIPAL FINDINGS Hospital volume was associated with significantly reduced intraoperative durations and significantly increased probability of aspirin, β-blocker, and lipid-lowering discharge medication use. The proportion of outcome variability due to unobserved hospital × surgeon interaction effects was small but meaningful for intraoperative practices, discharge destination, and medication use. For readmissions and mortality within 30 days or 1 year, unobserved patient and hospital factors drove almost all variability in outcomes. CONCLUSIONS Among Massachusetts patients receiving isolated CABG, consistent evidence was found that the hospital × surgeon combination independently impacted patient outcomes, beyond hospital or surgeon effects. Such distinct local interactions between a surgeon and hospital resources may play an important part in moderating quality improvement efforts, although residual patient-level factors generally contributed the most to outcome variability.
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Affiliation(s)
- Marco D Huesch
- Duke University, The Fuqua School of Business, 100 Fuqua Drive, Box 90120, Durham, NC 27708-0120, USA.
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Rahilly-Tierney CR, Nash IS. Decision-making in percutaneous coronary intervention: a survey. BMC Med Inform Decis Mak 2008; 8:28. [PMID: 18578880 PMCID: PMC2443120 DOI: 10.1186/1472-6947-8-28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 06/25/2008] [Indexed: 11/24/2022] Open
Abstract
Background Few researchers have examined the perceptions of physicians referring cases for angiography regarding the degree to which collaboration occurs during percutaneous coronary intervention (PCI) decision-making. We sought to determine perceptions of physicians concerning their involvement in PCI decisions in cases they had referred to the cardiac catheterization laboratory at a major academic medical center. Methods An anonymous survey was mailed to internal medicine faculty members at a major academic medical center. The survey elicited whether responders perceived that they were included in decision-making regarding PCI, and whether they considered such collaboration to be the best process of decision-making. Results Of the 378 surveys mailed, 35% (133) were returned. Among responding non-cardiologists, 89% indicated that in most cases, PCI decisions were made solely by the interventionalist at the time of the angiogram. Among cardiologists, 92% indicated that they discussed the findings with the interventionalist prior to any PCI decisions. When asked what they considered the best process by which PCI decisions are made, 66% of non-cardiologists answered that they would prefer collaboration between either themselves or a non-interventional cardiologist and the interventionalist. Among cardiologists, 95% agreed that a collaborative approach is best. Conclusion Both non-cardiologists and cardiologists felt that involving another decision-maker, either the referring physician or a non-interventional cardiologist, would be the best way to make PCI decisions. Among cardiologists, there was more concordance between what they believed was the best process for making decisions regarding PCI and what they perceived to be the actual process.
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Affiliation(s)
- Catherine R Rahilly-Tierney
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston VA Healthcare System, Boston, Massachusetts, USA.
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Affiliation(s)
- David P Taggart
- Professor of Cardiovascular Surgery, University of Oxford, Oxford, UK
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