Factors affecting mortality after coronary bypass surgery: a scoping review.

OBJECTIVES: Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded. METHODS: We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care. RESULTS: We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects. CONCLUSIONS: Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery.

The Impact of Pre-Procedural Renal Impairment on Outcomes Following Percutaneous Coronary Intervention: An Analysis of 45,287 Patients From the British Columbia Cardiac Registry.

BACKGROUND: Renal disease confers a strong independent risk for morbidity and mortality after percutaneous coronary intervention (PCI). We evaluated the relationship between baseline pre-procedural renal function and outcomes following PCI. METHODS: We examined 45,287 patients who underwent PCI in British Columbia. We evaluated all-cause mortality and target vessel revascularisation (TVR) at 2 years. Pre-procedural renal impairment was categorised by creatinine clearance (CrCl, mL/min): CrCl≥90 (n=14,876), 90>CrCl≥60 (n=10,219), 60>CrCl≥30 (n=14,876), 30>CrCl≥0 (n=2,594) and dialysis (n=579). RESULTS: Declining CrCl values less than 60 mL/min were progressively associated with greater mortality: 60>eGFR≥30 (HR=2.01, 95% CI 1.71-2.37, p<0.001); 30>eGFR≥0 (HR=4.10, 95% CI 3.39-4.95, p<0.001); and dialysis (HR=6.22, 95% CI 5.07-7.63, p<0.001). A reduction in eGFR was not associated with TVR in non-dialysis patients. However, dialysis was a strong independent predictor for TVR (HR=1.69, 95% CI 1.37-2.08, p<0.001). This was confirmed in propensity-matched analyses where, dialysis was strongly associated with TVR (HR=1.53, 95% CI 1.24-1.89, p<0.001). This association was consistently seen in stratified analyses for diabetic versus non-diabetic patients; stent length >30 mm versus <30 mm; stent diameter >3 mm versus <3 mm; and receipt of bare metal stents versus drug-eluting stents. CONCLUSIONS: This study indicates the association with declining renal function and mortality in patients undergoing PCI. Whilst renal disease was not associated with increased TVR in non-dialysis patients, dialysis-dependence was a strong independent predictor for increased TVR.

Quality-of-Life Outcomes After Transcatheter Aortic Valve Implantation in a "Real World" Population: Insights From a Prospective Canadian Database.

BACKGROUND: Documentation of quality of life (QOL) of patients after transcatheter aortic valve implantation (TAVI) is a Canadian Cardiovascular Society quality indicator. National results have not been reported to date. METHODS: We conducted an observational cohort study including all TAVI patients, irrespective of surgical risk, treated between January 2016 and June 2019 as documented in the British Columbia TAVI Registry. QOL was measured at baseline, 30 days, and 1 year, using the Kansas City Cardiomyopathy Questionnaire overall score (KCCQ-OS). We used linear regression modelling to examine factors associated with 30-day changes in QOL, logistic regression modelling to identify predictors of sustaining a poor outcome, and Cox regression modelling to ascertain risk estimates of the effect of QOL on 1-year mortality. RESULTS: The cohort included 1706 patients (742 women [43.5%]); median age 83 years (interquartile range [IQR]: 77, 86). Median (IQR) baseline KCCQ-OS was 45 (28.2, 67), indicating severe impairment. Patients alive at 1 year (91.3%) reported a mean improvement of 24.1 (95% confidence interval [CI], 22.7-25.6) points in the KCCQ-OS at 30 days, which was sustained at 1 year (25.3; 95% CI, 23.8, 26.8). Older age, lower baseline health status, lower aortic valve gradient, lower hemoglobin, atrial fibrillation, and non-transfemoral access were associated with worse 30-day QOL. At 1 year, 65% of patients had a favorable outcome; additional risk factors for 1-year mortality (8.7%) were male sex, New York Heart Association Class IV, severe pulmonary and renal disease, diabetes, and in-patient status. CONCLUSIONS: TAVI is associated with significant early improvement in QOL, which is sustained at 1 year. The inclusion of QOL can support treatment decisions and patient-centred evaluation.

INTRODUCTION: Les données sur la qualité de vie (QdV) des patients après l'implantation valvulaire aortique par cathéter (IVAC) sont un indicateur de qualité de la Société canadienne de cardiologie. Jusqu'à ce jour, les résultats nationaux n'ont pas été présentés. MÉTHODES: Nous avons mené une étude de cohorte observationnelle portant sur tous les patients ayant subi une IVAC, sans tenir compte du risque lié à l'intervention chirurgicale, qui ont été traités entre janvier 2016 et juin 2019 selon le registre d'IVAC de la Colombie-Britannique. L'évaluation de la QdV a été établie au début, 30 jours après et 1 an après au moyen du score global au Kansas City Cardiomyopathy Questionnaire (SG-KCCQ). Nous avons utilisé le modèle de régression linéaire pour examiner 30 jours après les facteurs associés aux changements dans la QdV, le modèle de régression logistique pour déterminer les prédicteurs du maintien d'issues médiocres et le modèle de régression de Cox pour établir les estimations du risque en fonction des effets de la QdV sur la mortalité 1 un après. RÉSULTATS: La cohorte regroupait 1 706 patients (742 femmes [43,5 %]); l'âge médian était de 83 ans (écart interquartile [ÉI] : 77; 86). Le SG-KCCQ médian (ÉI) au début était de 45 (28,2; 67), soit une détérioration importante. Les patients en vie un an après (91,3 %) ont signalé une amélioration moyenne de 24,1 (intervalle de confiance [IC] à 95 %, 22,7-25,6) points au SG-KCCQ 30 jours après, qui a été maintenue jusqu'à un an (25,3; IC à 95 %; 23,8; 26,8). L'âge avancé, l'état de santé initial inférieur, le gradient de la valve aortique plus faible, l'hémoglobine plus faible, la fibrillation auriculaire et l'accès non transfémoral ont été associés à une plus mauvaise qualité de vie 30 jours après. Un an après, 65 % des patients avaient des issues favorables; les facteurs additionnels de risque de mortalité un an après (8,7 %) étaient le sexe masculin, la classe IV selon la New York Heart Association, la pneumopathie et la néphropathie graves, le diabète et l'état du patient hospitalisé. CONCLUSIONS: L'IVAC est associée à une amélioration précoce significative de la QdV, qui est maintenue un an après. L'inclusion de la QdV peut contribuer aux décisions de traitement et à l'évaluation axée sur le patient.

Cardiovascular Care Delivery During the Second Wave of COVID-19 in Canada.

Hospitals and ambulatory facilities significantly reduced cardiac care delivery in response to the first wave of the COVID-19 pandemic. The deferral of elective cardiovascular procedures led to a marked reduction in health care delivery with a significant impact on optimal cardiovascular care. International and Canadian data have reported dramatically increased wait times for diagnostic tests and cardiovascular procedures, as well as associated increased cardiovascular morbidity and mortality. In the wake of the demonstrated ability to rapidly create critical care and hospital ward capacity, we advocate a different approach during the second and possible subsequent COVID-19 pandemic waves. We suggest an approach, informed by local data and experience, that balances the need for an expected rise in demand for health care resources to ensure appropriate COVID-19 surge capacity with continued delivery of essential cardiovascular care. Incorporating cardiovascular care leaders into pandemic planning and operations will help health care systems minimise cardiac care delivery disruptions while maintaining critical care and hospital ward surge capacity and continuing measures to reduce transmission risk in health care settings. Specific recommendations targeting the main pillars of cardiovascular care are presented: ambulatory, inpatient, procedural, diagnostic, surgical, and rehabilitation.

Guiding Cardiac Care During the COVID-19 Pandemic: How Ethics Shapes Our Health System Response.

The COVID-19 pandemic has raised ethical questions for the cardiovascular leader and practitioner. Attention has been redirected from a system that focuses on individual patient benefit toward one that focuses on protecting society as a whole. Challenging resource allocation questions highlight the need for a clearly articulated ethics framework that integrates principled decision making into how different cardiovascular care services are prioritized. A practical application of the principles of harm minimisation, fairness, proportionality, respect, reciprocity, flexibility, and procedural justice is provided, and a model for prioritisation of the restoration of cardiovascular services is outlined. The prioritisation model may be used to determine how and when cardiovascular services should be continued or restored. There should be a focus on an iterative and responsive approach to broader health care system needs, such as other disease groups and local outbreaks.

Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care.

Cardiac rehabilitation programs across Canada have suspended in-person services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time.