Challenging the status quo: A scoping review of value-based care models in cardiology and electrophysiology.

BACKGROUND AND OBJECTIVE: The accomplishment of value-based healthcare (VBHC) models could save up to $1 trillion per year for healthcare systems worldwide while improving patients' wellbeing and experience. Nevertheless, its adoption and development are challenging. This review aims to provide an overview of current literature pertaining to the implementation of VBHC models used in cardiology, with a focus on cardiac electrophysiology. MATERIAL AND METHODS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews. The records included in this publication were relevant documents published in PubMed, Mendeley and ScienceDirect. The search criteria were publications about VBHC in the field of cardiology and electrophysiology published between 2006 and 2023. RESULTS: The implementation of VBHC models in cardiology and electrophysiology is still in its infant stages. There is a clear need to modify the current organizational structure in order to establish cross-functional teams with the patient at the center of care. The adoption of new reimbursement schemes is crucial to moving this process forward. The implementation of technologies for data analysis and patient management, among others, poses challenges to the change process. CONCLUSION: New VBHC models have the potential to improve the care process and patient experience while optimizing the costs. The implementation of this model has been insufficient mainly because it requires substantial changes in the existing infrastructures and local organization, the need to track adherence to guidelines and the evaluation of the quality of life improvement and patient satisfaction, among others.

Predictors of the efficacy of His bundle pacing in patients with a prolonged PR interval: A stratified analysis of the HOPE-HF randomized controlled trial.

AIMS: The randomized, double-blind, placebo-controlled HOPE-HF trial assessed the benefit of atrio-ventricular (AV) delay optimization delivered using His bundle pacing. It recruited patients with left ventricular ejection fraction ≤40%, PR interval ≥200 ms, and baseline QRS ≤140 ms or right bundle branch block. Overall, there was no significant increase in peak oxygen uptake (VO2max) but there was significant improvement in heart failure specific quality of life. In this pre-specified secondary analysis, we evaluated the impact of baseline PR interval, echocardiographic E-A fusion, and the magnitude of acute high-precision haemodynamic response to pacing, on outcomes. METHODS AND RESULTS: All 167 randomized participants underwent measurement of PR interval, acute haemodynamic response at optimized AV delay, and assessment of presence of E-A fusion. We tested the impact of these baseline parameters using a Bayesian ordinal model on VO2max, quality of life and activity measures. There was strong evidence of a beneficial interaction between the baseline acute haemodynamic response and the blinded benefit of pacing for VO2 (Pr 99.9%), Minnesota Living With Heart Failure (MLWHF) (Pr 99.8%), MLWHF physical limitation score (Pr 98.9%), EQ-5D visual analogue scale (Pr 99.6%), and exercise time (Pr 99.4%). The baseline PR interval and the presence of baseline E-A fusion did not have this reliable ability to predict the clinical benefit of pacing over placebo across multiple endpoints. CONCLUSIONS: In the HOPE-HF trial, the acute haemodynamic response to pacing reliably identified patients who obtained clinical benefit. Patients with a long PR interval (≥200 ms) and left ventricular impairment who obtained acute haemodynamic improvement with AV-optimized His bundle pacing were likely to obtain clinical benefit, consistent across multiple endpoints. Importantly, this gradation can be reliably tested for before randomization, but does require high-precision AV-optimized haemodynamic assessment to be performed.

Same-day discharge vs. overnight stay following catheter ablation for atrial fibrillation: a comprehensive review and meta-analysis by the European Heart Rhythm Association Health Economics Committee.

AIMS: Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS). METHODS AND RESULTS: A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term (24-96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1-5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1-4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52-5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42-1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1-10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58-1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0-1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design. CONCLUSION: In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies.

Shared Decision-making in Breast Cancer Reconstructive Surgery: Experience in a Leading Hospital.

Background: The paradigm of healthcare has evolved toward patient-centered approaches, where shared decision-making (SDM) plays a pivotal role. This study aimed to explore the implementation of SDM during breast cancer reconstruction consultations and assess its impact on patient satisfaction and the decision-making process as a whole. Methods: A total of 102 female patients undergoing breast reconstruction were included in a multidisciplinary breast pathology unit. A streamlined SDM model involving choice introduction, option description, and preference exploration was implemented. A validated Spanish version of the nine-item Shared Decision Making Questionnaire was used alongside a complementary questionnaire. Data analysis was carried out using electronic data capture software. Results: The nine-item Shared Decision Making Questionnaire results indicate strong agreement in presenting various options and explaining their advantages and disadvantages. Patients were less confident about their participation in decision-making. The Complementary Shared Decision Making Questionnaire highlighted high satisfaction with interview times and language clarity but areas for improvement in consultation space and therapeutic choice participation. Conclusions: Integrating SDM into breast reconstruction consultations empowers patients in the decision-making process and enhances satisfaction. Decision aids prove effective in this context, facilitating patients' comprehension and reducing decisional conflict. There are areas for improvement within the SDM strategy, and they are detectable through scales. Although challenges in information transmission and patient involvement persist, adopting an SDM model has potential benefits that warrant further investigation.

Características clínicas de gestantes en trabajo de parto con infección SARSCoV-2 en la altura: serie de casos / Clinical characteristics of pregnant women in labor with SARS-CoV-2 infection at high altitude: A case series

Resumen Introducción. A gran altitud, se ha observado menos casos y menos letalidad de COVID-19 en comparación con cifras reportadas a nivel del mar. Actualmente no hay publicaciones que informen el comportamiento clínico de COVID-19 en mujeres embarazadas adaptadas a la altura e hipoxia crónica en el Perú. Métodos. Estudio retrospectivo mediante revisión de historias clínicas del 6 de marzo de 2020 al 15 de junio de 2020. Se describe los primeros trece casos de gestantes con COVID-19 atendidos en el Hospital COVID-19 Simón Bolívar, ubicado a 2 750 msnm. Los casos procedían de altitudes entre 2 035 msnm y 3 502 msnm. El análisis estadístico se realizó con SPSS, versión 19.0. Resultados. Trece casos de gestantes con COVID-19 confirmado por IGM para SARS-CoV-2, fueron tratadas a 2 750 msnm (9 022,31 pies), en los Andes peruanos. El parto fue por cesárea en ocho casos (61,5%) y por vía vaginal en cinco (38,5%). Hubo dos casos (15,4%) de preeclampsia, uno de ellos diagnosticado como síndrome HELLP, prematuridad y muerte fetal. Tres casos (23,1%) desarrollaron hipotonía uterina posparto y requirieron sutura de Hayman o B-Lynch. Dos casos (15,4%) se complicaron con oligohidramnios y otros dos casos con infección urinaria. Los niveles de hemoglobina variaron entre 11,1 y 16 g/dL. Solo un caso (7,7%) presentó sintomatología, con dolor faríngeo leve. No se observó transmisión vertical detectada por IgM/IgG para SARS-CoV-2. La evolución clínica fue favorable en los trece casos y el alta fue a los 2 a 4 días, para continuar la cuarentena en domicilio. Conclusiones. En el presente estudio preliminar, las gestantes en trabajo de parto con COVID-19 por prueba rápida IgM para SARS-CoV-2 en la altura fueron generalmente asintomáticas; no hubo transmisión vertical. Se presentó alto porcentaje de otras complicaciones obstétricas.

Abstract Introduction: Fewer COVID-19 cases and less lethality have been observed at high altitude compared to cases reported at sea level. There are currently no publications reporting clinical behavior of pregnant women with COVID-19 at high altitude. Methods: This is a retrospective study with review of medical records between March 6, 2020 and June 15, 2020. The first thirteen cases of pregnant women with COVID-19 who were attended at Simón Bolívar COVID-19 Hospital, located at 2 750 meters above sea level, are described. The cases came from altitudes between 2 035 and 3 502 meters above sea level (masl). Statistical analysis used SPSS, version 19.0. Results: Thirteen cases of pregnant women with COVID-19 confirmed by IgM for SARS-CoV-2 were attended at 2 750 masl (9 022.31 feet) in the Peruvian Andes. Delivery by cesarean section occurred in eight cases (61.5%) and five (38.5%) delivered vaginally. There were two cases (15.4%) of preeclampsia, one with diagnosis of HELLP syndrome, prematurity and fetal death. Three cases (23.1%) developed uterine hypotonia that required Hayman or B-Lynch suture. Two cases (15.38%) were complicated with oligohydramnios and two with urinary infection. Hemoglobin levels were between 11.1 and 16 g/dL. Only one case (7.7%) was symptomatic, with mild pharyngeal pain. No vertical transmission was detected by IgM/IgG for SARS-CoV-2. Clinical evolution was favorable in the thirteen cases and they were discharged after 2 to 4 days hospitalization to continue home quarantine. Conclusions: Results in this short study show pregnant women in labor with COVID-19 by rapid IgM test for SARS-CoV-2 at high altitude were mostly asymptomatic; there was no vertical transmission, but high presence of other obstetrical complications.

Maternal mortality in pregnant women with positive SARS-CoV-2 antibodies and severe preeclampsia. Report of 3 cases / Mortalidad materna en gestantes con anticuerpos a SARS-CoV-2 positivos y preeclampsia severa. Reporte de 3 casos

Abstract Maternal mortality from COVID-19 is rare in developed countries, but its association with other obstetric complications increases the risk. It is also associated with fetal death. Postpartum women are at risk of thrombosis that increases with COVID-19 coagulopathy. Comorbidities such as obesity, diabetes, and hypertension increase the risk of death from COVID-19, and pregnant women have more complications during the third trimester than in the first trimester, with higher risk than non pregnant women of entering the ICU and requiring mechanical ventilation. In this report, stroke, diabetes and intracerebral hemorrhage were the three causes of death described, all within the context of stillbirth, severe preeclampsia, eclampsia and/or HELLP syndrome.

Resumen La mortalidad materna por COVID-19 es poco frecuente en países desarrollados, pero su asociación a otras complicaciones obstétricas aumenta el riesgo. Además, está asociada a muerte fetal. Las puérperas, tienen riesgo de trombosis que se incrementa con la coagulopatía por COVID-19. Las comorbilidades como obesidad, diabetes, hipertensión incrementan el riesgo de muerte asociada a COVID-19 y las gestantes en el tercer trimestre se complican más que en el primero, teniendo más riesgo que las mujeres no gestantes de ingresar a UCI y requerir ventilación mecánica. En este reporte, el accidente cerebrovascular isquémico y hemorrágico y la diabetes fueron las tres causas de muerte, todas en un contexto de óbito fetal, preeclampsia severa, eclampsia y/o síndrome HELLP.

Complicación de derivación ventrículo-auricular para tratamiento de la hidrocefalia: informe de un caso poco usual / Ventriculovenous shurt complication for the treatment of hidrocephalus: report of a unusual case

Presentamos el caso de un niño de 11 años de edad con hidrocefalia a quien se instaló sistema derivativo ventrículo-auricular V-A) y presentó como complicación ruptura de porción del catéter distal, con alojamiento en cavidades cardiacas derechas. Desarolló endocarditis bacteriana que se resolvió con tratamiento médico; para una cura definitiva se debió extraer el catéter no radio-opaco quirúrgicamente. La localización del catéter intracardiaco se realizó con ecocardiografía bidimensional