Preoperative Heart Failure Treatment Prevents Postoperative Cardiac Complications in Patients With Lower Risk: A Retrospective Cohort Study.

OBJECTIVE: The objective of this study was to identify undertreated subgroups of patients with heart failure who would benefit from better perioperative optimization. SUMMARY OF BACKGROUND DATA: Patients with heart failure have increased risks of postoperative cardiac complications after noncardiac surgery. METHODS: In this analysis of hospital registry data of 130,677 patients undergoing noncardiac surgery, the exposure was preoperative history of heart failure. The outcome, cardiac complications, was defined as a composite of myocardial infarction, cardiac arrest, acute heart failure, and mortality within 30 postoperative days. RESULTS: History of heart failure (n = 10,256; 7.9%) was associated with increased risk of cardiac complications [8.1% vs 1.1%; adjusted odds ratio, 2.28 (95% CI, 2.02-2.56); P < 0.001). Patients with heart failure and who carried a lower risk profile had increased risks of postoperative cardiac complications secondary to heart failure [adjusted absolute risk difference, 1.7% (95% CI, 1.4%-2.0%, lower risk); P < 0.001 vs 0.5% (95% CI, -0.6% to 1.6%, higher risk); P = 0.38]. Patients with heart failure and lower risk received a lower level of health care utilization preoperatively, and less frequently received anti-heart failure medications (59% vs 72% and 61% vs 82%; both P < 0.001). These preventive therapies significantly decreased the risk of cardiac complications in patients with heart failure. CONCLUSIONS: In patients with heart failure who have a lower preoperative risk profile, clinicians often make insufficient attempts to optimize their clinical condition preoperatively. Preoperative preventive treatment reduces the risk of postoperative cardiac complications in these lower-risk patients with heart failure.

Multidisciplinary team approach to confront the challenge of drug use-associated infective endocarditis.

OBJECTIVES: Drug use-associated infective endocarditis is a rapidly growing clinical problem. Although operative outcomes are generally satisfactory, reinfection secondary to recurrent substance use is distressingly common, negatively affects long-term survival, generates practical and ethical challenges, and creates potential conflict among care team members. We established a Drug Use Endocarditis Treatment team including surgeons, infectious disease, and addiction medicine experts specifically focused on the unique complexities of drug use-associated infective endocarditis. METHODS: We reviewed the impact of Drug Use Endocarditis Treatment team involvement on quantitative measures of quality of care, including length of stay, time to addiction medicine consultation, time to surgery, and discharge on appropriate medications for opioid use disorder, as well as operative mortality. Standard statistical tests were used, including the Fisher exact test, t test, and Wilcoxon rank-sum test. Qualitative assessment was made of the impact on clinicians, including communication and mutual understanding. RESULTS: Comparing the pre-Drug Use Endocarditis Treatment cohort with the post-Drug Use Endocarditis Treatment cohort, patients in the post-Drug Use Endocarditis Treatment cohort who underwent surgery had a significantly lower time from admission to addiction medicine consultation (3.8 vs 1.0 days P < .001) and clinically relevant increase in discharge on medications for opioid use disorder (48% vs 67% P = .35). Additionally, involved members of the team thought communication was improved. CONCLUSIONS: The Drug Use Endocarditis Treatment team improved engagement with addiction medicine consultation and appropriate discharge care. Given the impact of relapse of injection drug use on long-term outcomes, interventions such as this offer potentially powerful tools for the treatment of this complex patient population.

Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review.

The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.

Creation of a Multidisciplinary Drug Use Endocarditis Treatment (DUET) Team: Initial Patient Characteristics, Outcomes, and Future Directions.

BACKGROUND: Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use-associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. METHODS: The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE. RESULTS: Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge. CONCLUSIONS: Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model.

Incidental Discovery of an Atypical Cardiac Tumor.

Primary cardiac tumors are rare, present in roughly 0.05% of the population. Cardiac papillary fibroelastoma (CPF) is the second most common, accounting for 10% of primary cardiac tumors.[1] Most cases of CPFs are discovered incidentally on autopsy; however, they may present clinically with systemic embolization or heart failure symptoms. The recommended treatment for symptomatic CPF patients is surgical resection.[1] Treatment in asymptomatic patients remains somewhat controversial with incidentally discovered tumors presenting a clinical dilemma. We present a case of an atypically located CPF that was discovered incidentally on intraoperative transesophageal echocardiography (TEE) during a routine coronary artery bypass graft operation. This case highlights several important points for cardiac anesthesiologists. The first is the importance of performing a comprehensive intraoperative TEE. Next, this case reinforces the broad utility of TEE for evaluation of intracardiac tumors. Finally, this case demonstrates the importance of precise localization of intracardiac tumors.

Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT).

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.

Interventional Treatment of Pulmonary Embolism.

Pulmonary embolism (PE) is a serious and prevalent cause of vascular disease. Nevertheless, optimal treatment for many phenotypes of PE remains uncertain. Treating PE requires appropriate risk stratification as a first step. For the highest-risk PE, presenting as shock or arrest, emergent systemic thrombolysis or embolectomy is reasonable, while for low-risk PE, anticoagulation alone is often chosen. Normotensive patients with PE but with indicia of right heart dysfunction (by biomarkers or imaging) constitute an intermediate-risk group for whom there is controversy on therapeutic strategy. Some intermediate-risk patients with PE may require urgent stabilization, and ≈10% will decompensate hemodynamically and suffer high mortality, though identifying these specific patients remains challenging. Systemic thrombolysis is a consideration, but its risks of major and intracranial hemorrhages rival overall harms from intermediate PE. Multiple hybrid pharmacomechanical approaches have been devised to capture the benefits of thrombolysis while reducing its risks, but there is limited aggregate clinical experience with such novel interventional strategies. One method to counteract uncertainty and generate a consensus multidisciplinary prognostic and therapeutic plan is through a Pulmonary Embolism Response Team, which combines expertise from interventional cardiology, interventional radiology, cardiac surgery, cardiac imaging, and critical care. Such a team can help determine which intervention-catheter-directed fibrinolysis, ultrasound-assisted thrombolysis, percutaneous mechanical thrombus fragmentation, or percutaneous or surgical embolectomy-is best suited to a particular patient. This article reviews these various modalities and the background for each.

A 57-Year-Old Man With Insidious Dyspnea and Nonpleuritic Chest and Back Pain.

A 57-year-old man with a history of DVT and pulmonary embolism, transient ischemic attacks, prior 60 pack-year smoking history, and oxygen-dependent COPD presented with insidiously worsening dyspnea associated with new pleuritic chest and back pain.

Effect of Educational Intervention on the Rate of Rarely Appropriate Outpatient Echocardiograms Ordered by Attending Academic Cardiologists: A Randomized Clinical Trial.

Importance: Appropriate use criteria-based educational initiatives have been shown to improve transthoracic echocardiography (TTE) ordering practices of physicians in training. Whether such an intervention is successful with attending cardiologists remains unknown. Objective: To prospectively investigate the effect of an appropriate use criteria-based educational intervention on ordering of outpatient TTEs by attending academic cardiologists. Design, Setting, and Participants: We conducted a prospective, randomized clinical trial of an educational intervention designed to reduce the number of outpatient TTEs that were deemed to be rarely appropriate by published appropriate use criteria. Investigators classifying TTEs were blinded to participant groupings. The study was conducted within the cardiology division at the Massachusetts General Hospital, an academic quaternary care hospital. Staff members of the cardiology division were included; 66 cardiologists were randomized. The study was conducted from November 19, 2013, to June 1, 2014. An analysis of the evaluable population was performed. Interventions: The appropriate use criteria-based educational intervention consisted of a review lecture and electronic information card, as well as monthly individual physician feedback via email. The email described the percentage of rarely appropriate TTEs as well as the appropriate use criteria rationale for classifying studies as rarely appropriate. Main Outcomes and Measures: We hypothesized a priori that the educational intervention would reduce the number of rarely appropriate TTEs. The primary outcome was the rate of rarely appropriate TTEs. Results: Of the 66 cardiologists enrolled in the study, 65 were included in the analysis (1 intervention cardiologist retired from practice during the study). The participants' mean (SD) age was 50.6 (10.5) years; 48 (73%) were men. Following intervention, the proportion of rarely appropriate TTEs was significantly lower in the intervention vs control group (143 of 1359 [10.5%] vs 285 of 1728 [16.5%]; odds ratio [OR], 0.59 [95% CI, 0.39-0.88]; P = .01), and there was a nonsignificant increase in the proportion of appropriate TTEs in the intervention vs control group (1054 [77.6%] vs 1244 [72.0%]; OR, 1.38 [95% CI, 0.93-2.05]; P = .11). The most common of the 428 rarely appropriate indications were routine surveillance within 3 years after prosthetic valve insertion (73 [17.1%]), routine surveillance within 1 year for moderate or severe valvular stenosis (64 [15.0%]), and routine surveillance of cardiomyopathy (45 [10.5%]) or ventricular function (36 [8.4%]). Conclusions and Relevance: An appropriate use criteria-based educational and feedback intervention reduced the number of rarely appropriate TTEs ordered by attending academic cardiologists. This strategy may be feasible to improve TTE utilization among cardiologists, and this type of intervention warrants study in other practice environments. Trial Registration: clinicalrials.gov Identifier: NCT01968642.

A Multidisciplinary Pulmonary Embolism Response Team: Initial 30-Month Experience With a Novel Approach to Delivery of Care to Patients With Submassive and Massive Pulmonary Embolism.

BACKGROUND: Integrating newly developed tests and treatments for severe pulmonary embolism (PE) into clinical care requires coordinated multispecialty collaboration. To meet this need, we developed a new paradigm: a multidisciplinary Pulmonary Embolism Response Team (PERT). In this report, we provide the first longitudinal analysis of patients treated by a PERT. METHODS: Our PERT includes specialists in cardiovascular medicine and surgery, emergency medicine, hematology, pulmonary/critical care, and radiology, and is organized as a rapid response team. We prospectively captured clinical, therapeutic, and outcome data at PERT activation and during follow-up periods up to 365 days. We analyzed data collectively, and as five mutually exclusive 6-month periods. We performed Fisher exact tests and regression analysis to test for trend. RESULTS: In 30 months, there were 394 unique PERT activations, 314 (80%) for confirmed PE. PERT activations increased by 16% every 6 months. Most confirmed PEs were submassive (n = 143, 46%) or massive (n = 80, 26%). The PERT treated a relatively large proportion of patients with PE and systemic or catheter-directed thrombolysis (n = 35, 11%), though the most common treatment was anticoagulation alone (n = 215, 69%). Hemorrhagic complications were rare overall, especially among patients treated with catheter-directed thrombolysis. The all-cause 30-day mortality of PERT patients with confirmed PE was 12%. CONCLUSIONS: We report our initial 30-month experience with a novel multidisciplinary PERT that rapidly engages multiple specialists to deliver efficient, organized, and evidence-based care to patients with high-risk PE. The PERT paradigm was rapidly adopted and may become a new standard of care for patients with PE.

Diagnosis and Management of Thoracic Aortic Disease.

Thoracic aortic aneurysms are typically asymptomatic and discovered incidentally on an imaging study ordered for other indications. Small aneurysms are managed with antihypertensive therapy and surveillance imaging, using either echocardiography, computed tomographic angiography (CTA), or magnetic resonance angiography (MRA). Aneurysms are repaired when the risk of rupture or dissection exceeds the risk of repair; size thresholds for repair are determined by the underlying etiology of the aneurysm, with lower thresholds for those with genetic aortopathies. In contrast to the silent and asymptomatic nature of aneurysms, acute aortic syndromes-which include aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer-are usually associated with recognizable symptoms and signs. Acute aortic syndromes involving the ascending aorta are treated with emergent surgery, whereas those involving the descending aorta are now often treated with endovascular stent-grafting techniques. After acute aortic syndromes have been successfully treated, prognosis is favorable with close follow-up that includes optimal medical management and regular surveillance imaging.