Comparison of Ambulatory Health Care Costs and Use Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy.

Importance: Studies comparing contemporary bariatric surgical types could facilitate procedure selection for patients interested in reducing their frequency of health care visits and reliance on prescription drugs. Objective: To compare the association of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) with ambulatory health care costs and use for as long as 4 years after surgery. Design, Setting, and Participants: This comparative effectiveness study, which included patients undergoing bariatric surgery who were aged 18 to 64 years with at least 24 months of enrollment data before surgery and 12 months of enrollment data after surgery, used a retrospective interrupted time series with a comparison group. Data represent insurance claims dated January 2006 to June 2017, with analyses completed in September 2021. Data were collected from US commercial and Medicare Advantage claims database. Cohorts were matched on characteristics including baseline body mass index category, diabetes status, baseline ambulatory care costs, region of the United States, and year of surgery. Exposures: SG or RYGB, based on procedure codes. Main Outcomes and Measures: Annual ambulatory health care costs, and subtypes of cost and use including prescriptions, office visits, laboratory encounters, and radiology. Results: Matched cohorts included 3049 patients who underwent SG and 3251 patients who underwent RYGB, with a mean (SD) age of 45.2 (10.0) years; 4820 (77%) were women. Full follow-up was 37% for SG (514 patients) and 38% for RYGB (643 patients) among those eligible for 4-year follow-up. There were no significant differences between SG and RYGB in total ambulatory costs, office visit costs, or radiology costs in all follow-up years. Patients who underwent SG had significantly higher prescription costs than those who underwent RYGB bypass in year 4 ($852.8 per patient per year; 95% CI: $395.6-$1310.0 per patient per year) with more cardiometabolic medication fills in each year (eg, year 4: 42.5%; 95% CI, 13.7%-71.2%). In contrast, early after surgery, patients who underwent SG had relatively fewer specialist visits (eg, year 1: -7.2%; 95% CI, -14.3% to -0.2%) and lower laboratory costs (eg, year 1: -$118.9 per patient per year; 95% CI, -$220.2 to -$17.5 per patient per year). Conclusions and Relevance: Despite clinical studies showing greater weight loss and comorbidity improvement with RYGB vs SG, this study found no difference in total ambulatory costs for as long as 4 years after SG and RYGB. These findings may reflect the trade-off between greater improvements in cardiometabolic health and additional surgery-related care among patients undergoing RYGB. Studies with longer follow-up time could determine whether greater sustained weight loss from RYGB eventually results in lower costs compared with SG.

Radiographically quantified sarcopenia and traditional cardiovascular risk assessment in predicting long-term mortality after endovascular aortic repair.

OBJECTIVE: This study evaluated radiographically quantified sarcopenia and the patient's comorbidity burden based on traditional cardiovascular risk assessment as potential predictors of long-term mortality after endovascular aortic repair (EVAR). METHODS: The study included 480 patients treated with standard EVAR for intact infrarenal abdominal aortic aneurysms. Patient characteristics, comorbidities, aneurysm dimensions, and other preoperative risk factors were collected retrospectively. Preoperative computed tomography was used to measure psoas muscle area (PMA) at the L3 level. Patients were divided into three groups based on American Society of Anesthesiologists (ASA) score and PMA. In the high-risk group, patients had sarcopenia (PMA <8.0 cm2 for males and <5.5 cm2 for females) and an ASA score of 4. In the medium-risk group, patients had either sarcopenia or an ASA score of 4. Patients in the low-risk group had no sarcopenia and the ASA score was less than 4. Risk factors for long-term mortality were determined using multivariable analysis. Kaplan-Meier survival estimates were calculated for all-cause mortality. RESULTS: Patients in the high- and medium-risk groups were older than those in the low-risk group (77 ± 7, 76 ± 6, and 74 ± 8 years, respectively, P < .01). Patients in the high-risk group had higher prevalence of coronary artery disease, pulmonary disease, and chronic kidney disease. There were no differences in 30-day or 90-day mortality between the groups. The independent predictors of long-term mortality were age, ASA score, PMA, chronic kidney disease, and maximum aneurysm sac diameter. The estimated 1-year mortality rates were 5% ± 2% for the low-risk, 5% ± 2% for the medium-risk, and 18% ± 5% for the high-risk group (P < .01). Five-year mortality estimates were 23% ± 4%, 36% ± 3%, and 60% ± 6%, respectively (P < .01). The mean follow-up time was 5.0 ± 2.8 years. CONCLUSIONS: Both ASA and PMA were strong predictors of increased mortality after elective EVAR. The combination of these two can be used as a simple risk stratification tool to identify patients in whom aneurysm repair or the intensive long-term surveillance after EVAR may be unwarranted.

The Impact of the COVID-19 Pandemic on Cardiac Procedure Wait List Mortality in Ontario, Canada.

BACKGROUND: The novel SARS-CoV-2 (COVID-19) pandemic has dramatically altered the delivery of healthcare services, resulting in significant referral pattern changes, delayed presentations, and procedural delays. Our objective was to determine the effect of the COVID-19 pandemic on all-cause mortality in patients awaiting commonly performed cardiac procedures. METHODS: Clinical and administrative data sets were linked to identify all adults referred for: (1) percutaneous coronary intervention; (2) coronary artery bypass grafting; (3) valve surgery; and (4) transcatheter aortic valve implantation, from January 2014 to September 2020 in Ontario, Canada. Piece-wise regression models were used to determine the effect of the COVID-19 pandemic on referrals and procedural volume. Multivariable Cox proportional hazards models were used to determine the effect of the pandemic on waitlist mortality for the 4 procedures. RESULTS: We included 584,341 patients who were first-time referrals for 1 of the 4 procedures, of whom 37,718 (6.4%) were referred during the pandemic. The pandemic period was associated with a significant decline in the number of referrals and procedures completed compared with the prepandemic period. Referral during the pandemic period was a significant predictor for increased all-cause mortality for the percutaneous coronary intervention (hazard ratio, 1.83; 95% confidence interval, 1.47-2.27) and coronary artery bypass grafting (hazard ratio, 1.96; 95% confidence interval, 1.28-3.01), but not for surgical valve or transcatheter aortic valve implantation referrals. Procedural wait times were shorter during the pandemic period compared with the prepandemic period. CONCLUSIONS: There was a significant decrease in referrals and procedures completed for cardiac procedures during the pandemic period. Referral during the pandemic was associated with increased all-cause mortality while awaiting coronary revascularization.

The Cost of Innovation and Evidence in Cardiac Surgery.

This review summarizes a systematic analysis of 216 randomized trials of cardiovascular interventions performed during 2008-2019, according to the source of trial funding. The systematic analysis showed that on average the results of each trial would change significance if only 5 patients experienced different outcomes. Industry-sponsored trials were more likely to use composite endpoints, noninferiority designs, and twice as likely as nonindustry trials to report results favoring the device arm. Over 80% of industry trials used reporting strategies or "spin" suggesting the device arm was advantageous versus fewer than half of non-industry trials. The review discusses the implications of these findings.

Coronary Artery Bypass Grafting in Cancer Patients: Prevalence and Outcomes in the United States.

OBJECTIVE: To characterize the contemporary efficacy and utilization patterns of coronary artery bypass grafting (CABG) in specific cancer types. METHODS: We leveraged the data from the National Inpatient Sample and plotted trends of utilization and outcomes of isolated CABG (with no other additional surgeries during the same hospitalization) procedures from January 1, 2003, through September 1, 2015. Propensity score matching was used to assess for potential differences in outcomes by type of cancer status among contemporary (2012-2015) patients. RESULTS: Overall, the utilization of CABG decreased over time (250,677 in 2003 vs 134,534 in 2015, P<.001). However, the proportion of those with comorbid cancer increased (7.0% vs 12.6%, P<.001). Over time, in-hospital mortality associated with CABG use in cancer remained unchanged (.9% vs 1.0%, P=.72); yet, cancer patients saw an increase in associated major bleeding (4.5% vs 15.3%, P<.001) and rate of stroke (.9% vs 1.5%, P<.001) over time. In-hospital cost-of-care associated with CABG-use in cancer also increased over time ($29,963 vs $33,636, P<.001). When stratified by cancer types, in-hospital mortality was not higher in breast, lung, prostate, colon cancer, or lymphoma versus non-cancer CABG patients (all P>.05). However, there was a significantly higher prevalence of major bleeding but not stroke in patients with breast and prostate cancer only compared with non-cancer CABG patients (P<.01). Discharge dispositions were not found to be different between cancer sub-groups and non-cancer patients (P>.05), except for breast cancer patients who had lower home care, but higher skilled care disposition (P<.001). CONCLUSION: Among those undergoing CABG, the prevalence of comorbid cancer has steadily increased. Outside of major bleeding, these patients appear to share similar outcomes to those without cancer indicating that CABG utilization should be not be declined in cancer patients when otherwise indicated. Further research into the factors underlying the decision to pursue CABG in specific cancer sub-groups is needed.

Telehealth in Pediatric Heart Transplant Patients: Exercise, Nutrition, and Parental Imaging.

Telehealth is a promising new tool in medicine that has changed the landscape of medical care. The benefits of telehealth technology are immense, including improved access to care and potential savings in monetary and opportunity costs. Current challenges of incorporating telehealth services into regular clinical care include licensure and regulatory barriers, difficulty obtaining insurance reimbursements, and high costs of setting up successful telehealth infrastructures. These challenges threaten telehealth's future scalability and expansion to reach all patients in need.

Non-Elective Pediatric Cardiac Catheterization During COVID-19 Pandemic: A New York Center Experience.

BACKGROUND: COVID-19 has led to major changes in hospital systems across the world. In an effort to reduce viral transmission, conserve resources, and in accordance with institutional and state mandates, all elective procedures and surgeries were postponed during the initial outbreak. Guidelines for case selection are limited and management for pediatric catheterization laboratories during this crisis is unprecedented. OBJECTIVES: To report the protocols and case selection of a high-volume pediatric cardiac catheterization laboratory in the epicenter of the novel coronavirus (COVID-19) pandemic. METHODS: All pediatric cardiac catheterization procedures from March 16, 2020 through May 10, 2020 were reviewed. Changes to case selection and periprocedural workflow are described. Data were collected on COVID-19 testing status and primary procedure type, and all procedures were classified by urgency. RESULTS: There were 52 catheterizations performed on 50 patients. Endomyocardial biopsies were the most common procedure (n = 27; 52%). Interventional and diagnostic procedures represented 27% (n = 14) and 21% (n = 11) of cases, respectively. Two emergent procedures (3.8%) were performed on patients with positive COVID-19 testing. Most cases were performed on patients with negative COVID-19 testing (n = 33; 94%). CONCLUSIONS: Adjusting to the COVID-19 pandemic in a high-volume pediatric cardiac catheterization laboratory can be safely and effectively managed by prioritizing emergent and urgent cases and modifying workflow operations. The experience of this center may assist other pediatric cardiac catheterization laboratories in adapting to similar practice changes as the pandemic continues to evolve.

The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a centre at the epicentre.

OBJECTIVES: The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery programme and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care and enable support for the hospital in terms of physical resources, providers and resident training. METHODS: In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our programme, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS: We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS: We recognize that individual programmes around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programmes to plan for the future.

Characteristics of Contemporary Randomized Clinical Trials and Their Association With the Trial Funding Source in Invasive Cardiovascular Interventions.

Importance: Changes in evidence-based practice and guideline recommendations depend on high-quality randomized clinical trials (RCTs). Commercial device and pharmaceutical manufacturers are frequently involved in the funding, design, conduct, and reporting of trials, the implications of which have not been recently analyzed. Objective: To evaluate the design, outcomes, and reporting of contemporary randomized clinical trials of invasive cardiovascular interventions and their association with the funding source. Design, Setting, and Participants: This cross-sectional study analyzed published RCTs between January 1, 2008, to May 31, 2019. The trials included those involving coronary, vascular and structural interventional cardiology, and vascular and cardiac surgical procedures. Main Outcomes and Measures: We assessed (1) trial characteristics, (2) finding of a statistically significant difference in the primary end point favoring the experimental intervention, (3) reporting of implied treatment advantage in trials without significant differences in primary end point, (4) existence of major discrepancies between registered and published primary outcomes, (5) number of patients whose outcomes would need to switch from a nonevent to an event to convert a significant difference in primary end point to nonsignificant, and (6) association with funding source. Results: Of the 216 RCTs analyzed, 115 (53.2%) reported having commercial sponsorship. Most trials had 80% power to detect an estimated treatment effect of 30%, and 128 trials (59.3%) used composite primary end points. The median (interquartile range [IQR]) sample size was 502 (204-1702) patients, and the median (IQR) follow-up duration was 12 (1.0-14.4) months. Overall, 123 trials (57.0%) reported a statistically significant difference in the primary outcome favoring the experimental intervention; reporting strategies that implied an advantage were identified in 55 (65.5%) of 84 trials that reported nonsignificant differences. Commercial sponsorship was associated with a statistically significantly greater likelihood of favorable outcomes reporting (exponent of regression coefficient ß, 2.80; 95% CI, 1.09-7.18; P = .03) and with the reporting of findings that are inconsistent with the trial results. Discrepancies between the registered and published primary outcomes were found in 82 trials (38.0%), without differences in trial sponsorship. A median (IQR) number of 5 (2.8-12.5) patients experiencing a different outcome would have change statistically significant results to nonsignificant. Commercial sponsorship was associated with a greater number of patients (exponent of regression coefficient ß, 1.29; 95% CI, 1.00-1.66; P = .04). Conclusions and Relevance: These results suggest that contemporary RCTs of invasive cardiovascular interventions are relatively small and fragile, have short follow-up, and have limited power to detect large treatment effects. Commercial support appeared to be associated with differences in trial design, results, and reporting.

Cardiac Surgery in Canada During the COVID-19 Pandemic: A Guidance Statement From the Canadian Society of Cardiac Surgeons.

On March 11, 2020, the World Health Organization declared that COVID-19 was a pandemic.1 At that time, only 118,000 cases had been reported globally, 90% of which had occurred in 4 countries.1 Since then, the world landscape has changed dramatically. As of March 31, 2020, there are now nearly 800,000 cases, with truly global involvement.2 Countries that were previously unaffected are currently experiencing mounting rates of the novel coronavirus infection with associated increases in COVID-19-related deaths. At present, Canada has more than 8000 cases of COVID-19, with considerable variation in rates of infection among provinces and territories.3 Amid concerns over growing resource constraints, cardiac surgeons from across Canada have been forced to make drastic changes to their clinical practices. From prioritizing and delaying elective cases to altering therapeutic strategies in high-risk patients, cardiac surgeons, along with their heart teams, are having to reconsider how best to manage their patients. It is with this in mind that the Canadian Society of Cardiac Surgeons (CSCS) and its Board of Directors have come together to formulate a series of guiding statements. With strong representation from across the country and the support of the Canadian Cardiovascular Society, the authors have attempted to provide guidance to their colleagues on the subjects of leadership roles that cardiac surgeons may assume during this pandemic: patient assessment and triage, risk reduction, and real-time sharing of expertise and experiences.

Profil évolutif de l'utilisation et des résultats cliniques de l'implantation valvulaire aortique par cathéter (TAVI) au Québec: évaluation en contexte réel de soins de 2013 à 2018 / Evolving portrait of the use and clinical outcomes of transcatheter aortic valve implantation (TAVI) in Québec: an evaluation in the real-world context of care, 2013 TO 2018

PRINCIPAUX CONSTATS: STRUCTURE ORGANISATIONNELLE: Le nombre d'interventions TAVI réalisées au Québec a augmenté de 294 en 2013- 2014 à 526 en 2017-2018, pour atteindre 30 % de tous les remplacements valvulaires aortiques (TAVI et RVA ± PAC); Le taux d'interventions TAVI, de 49 par million d'habitants en 2017-2018, suit la moyenne canadienne, mais demeure inférieur à celui observé en Ontario et en Colombie-Britannique; Depuis 2014-2015, tous les centres pratiquant des TAVI atteignent le volume minimal annuel recommandé en 2017 de 30 interventions [INESSS, 2017a]; La moitié des cardiologues interventionnistes pratiquant des TAVI au Québec ont effectué moins de 20 interventions par année, soit le volume minimal d'opérateur actuellement recommandé [INESSS, 2017a]. CARACTÉRISTIQUES DES PATIENTS: Une proportion importante des patients sélectionnés pour être traités par TAVI au Québec étaient âgés de plus de 85 ans et souffraient de comorbidités importantes et de symptômes limitant significativement l'activité physique (classes III et IV de la NYHA). PROCESSUS DE SÉLECTION DES PATIENTS ET DÉLAIS D'ATTENTE: Les processus de documentation se sont améliorés, notamment en ce qui a trait à: o la documentation du score de la STS (Society of Thoracic Surgery, mesure du risque prédit de mortalité opératoire) qui s'est améliorée d'une proportion de 50 % des patients en 2013-2014 à 72 % en 2017-2018; o la documentation d'une décision thérapeutique prise par une équipe multidisciplinaire qui est passée d'une proportion de 0 % des patients en 2013-2014 à 92 % en 2017-2018; o la documentation des dates nécessaires à la mesure des délais d'attente. En 2017-2018, la date de référence et la date de la décision thérapeutique par l'équipe multidisciplinaire étaient documentées chez plus de 9 patients sur 10. Délais d'attente: Depuis 2015-2016, le délai médian d'évaluation du patient (entre la référence et la décision thérapeutique) est d'environ 60 jours et suit la médiane canadienne. Le délai médian entre la décision relative au traitement et l'intervention a diminué depuis 2015-2016 à 32 jours en 2017-2018, ce qui est en deçà de la médiane canadienne de 56 jours. PROCESSUS DE SOINS LIÉS À L'INTERVENTION TAVI: À l'échelle provinciale, l'approche TAVI par voie d'accès transfémorale est la plus fréquemment utilisée (79 % des interventions en 2017-2018); Actuellement, deux grandes catégories de valves sont utilisées au Québec chez plus de 95 % des patients, c'est-à-dire le « balloon-expandable ¼ et le « selfexpandable ¼. Toutefois, ces deux catégories de valves sont en évolution technique constante et d'autres types de valves continuent d'émerger; Au moins deux opérateurs étaient présents dans la salle d'hémodynamie ou hybride durant l'intervention dans 88 % des interventions TAVI, en 2017-2018. Dans la majorité de ces cas, au moins un chirurgien cardiaque jouait le rôle de professionnel responsable ou de soutien pour la réalisation de l'intervention. PRINCIPAUX ÉVÈNEMENTS INDÉSIRABLES ET DURÉE DU SÉJOUR: De façon générale, l'incidence d'évènements indésirables péri et post-intervention a diminué avec le temps au Québec; L'incidence de conversion urgente vers un RVA est passée de 3 % en 2013-2014 à 0,2 % en 2017-2018, et la proportion de patients ayant plus d'une valve déployée a diminué de 7 % à 1 %; La proportion des patients ayant eu un saignement majeur a diminué de 13 % en 2013-2014 à 6 % en 2017-2018 (p < 0,05), avec une diminution de la variabilité des résultats entre les six programmes TAVI. La fréquence de transfusion pendant le séjour hospitalier (avant ou après l'intervention) a également diminué de 30 % en 2013-2014 à 16 % en 2017-2018 (p < 0,05); La fréquence d'implantation d'un nouveau stimulateur cardiaque permanent s'est maintenue au fil des années au niveau provincial, représentant 17 % des cas en 2017-2018, avec une variabilité observée selon les centres et les différents types de valves; L'incidence d'accidents vasculaires cérébraux (AVC) intrahospitaliers s'est maintenue entre 2,2 % et 4,4 %; La durée médiane du séjour hospitalier au centre d'interventions TAVI a diminué de 5 à 3 jours entre 2013-2014 et 2017-2018. La durée médiane pour la dernière année d'observation était de 2 jours chez les patients traités par voie transfémorale, la voie la plus fréquemment utilisée, et de 5 jours pour ceux traités par une autre voie d'accès. RÉSULTATS CLINIQUES: La proportion de patients de retour au domicile suivant le congé hospitalier a augmenté, passant de 74 % en 2013-2014 à environ 80 % en 2017-2018. Parallèlement, on observe une diminution de la proportion de patients décédés à l'établissement de l'intervention TAVI (de 6,5 % à 1,9 %), ou transférés vers un centre de soins de longue durée (de 5 % à 2 %). La proportion des patients orientés dans un autre centre hospitalier de soins de courte durée est demeurée relativement stable au fil des années (13 % en 2013-2014 et 14 % en 2017-2018). • L'incidence de mortalité à 30 jours a diminué, passant de 6,5 % en 2013-2014 à 2,7 % en 2017-2018 (p = 0,008), alors que l'incidence de mortalité à 1 an a diminué du tiers, soit de 14,6 % en 2013-2014 à 9,0 %, en 2017-2018 (p = 0,01).

MAIN FINDINGS: ORGANIZATIONAL STRUCTURE: The number of TAVIs performed in Québec increased from 294 in 2013-2014 to 526 in 2017-2018, at which time it accounted for 30% of all aortic valve replacements (TAVIs and SAVRs, with or without CABG, combined); The TAVI utilization rate of 49 per million population in 2017-2018 is similar to the Canadian average but is below that observed in Ontario and British Columbia; Since 2014-2015, all facilities performing TAVI have met the minimum annual volume of 30 procedures recommended in 2017 [INESSS, 2017a]; Half of interventional cardiologists performing TAVI in Québec carried out fewer than 20 procedures per year, which is the minimum operator volume currently recommended [INESSS, 2017a]. PATIENT CHARACTERISTICS: Many of the patients selected for treatment with TAVI in Québec were over 85 years of age and had major comorbidities and suffered symptoms that substantially limited their physical activity (NYHA classes III and IV). PATIENT SELECTION PROCESS AND WAIT TIMES: The documentation of processes has improved, particularly with regards to: documentation of the Society of Thoracic Surgery (STS) score, a measure of the predicted risk of surgical mortality, which improved from being present for 50% of patients in 2013-2014 to 72% in 2017-2018; the proportion of patients who had documentation that the treatment decision was made by a multidisciplinary team, which increased from 0% in 2013- 2014 to 92% in 2017-2018; the documentation of dates necessary for measuring wait times: in 2017- 2018, the date of referral and the date of the treatment decision by the multidisciplinary team were documented for more than 9 out of every 10 patients. WAIT TIMES: Since 2015-2016, the median time for patient assessment (from referral to treatment decision) has been maintained at approximately 60 days and is in line with the Canadian median. The median time from the treatment decision to the actual procedure has decreased since 2015-2016 to 32 days in 2017-2018, which is shorter than the Canadian median delay of 56 days. TAVI CARE PROCESSES: At the provincial level, the transfemoral access route was the most frequently used TAVI approach (in 79% of all interventions in 2017-2018); In Québec, two main categories of valves are currently used in more than 95% of patients, namely, balloon-expandable and self-expandable devices. However, these two categories of valves are in constant technical evolution, and other types of valves continue to emerge; In 2017-2018, at least two operators were present in the catheterization laboratory or hybrid room during 88% of the TAVI procedures. In most of these cases, a cardiac surgeon was either responsible for the treatment or had a supportive role. MAJOR ADVERSE EVENTS AND LENGTH OF HOSPITAL STAY: Overall, the incidence of peri- and post-procedural adverse events has decreased over time in Québec; The incidence of urgent conversion to SAVR decreased from 3% in 2013-2014 to 0.2% in 2017-2018, and the proportion of patients for whom more than one valve was deployed decreased from 7% to 1%; The frequency of implantation of a new permanent pacemaker has remained relatively unchanged over the years at the provincial level, accounting for 17% of the cases in 2017-2018, with variability being observed between the facilities and the different types of valves; The incidence of intrahospital stroke has remained between 2.2% and 4.4%; The median length of stay at TAVI centres decreased from 5 to 3 days between 2013-2014 and 2017-2018. The median length of stay in the most recent year of observation was 2 days for patients treated via the transfemoral approach (the most frequently used), and 5 days for those treated via alternative approaches. CLINICAL OUTCOMES: The proportion of patients who returned home at hospital discharge increased from 74% in 2013-2014 to approximately 80% in 2017-2018. During the same time period, there was a decrease in the proportion of patients who died at a TAVI facility (from 6.5% to 1.9%), or who were sent to a long-term care facility (from 5% to 2%). The proportion of patients transferred to another acute care hospital has remained relatively stable over the years (13% in 2013-2014 and 14% in 2017- 2018). The incidence of 30-day mortality decreased from 6.5% in 2013-2014 to 2.7% in 2017-2018 (p=0.008), while 1-year mortality decreased by a third, from 14.6% in 2013-2014 to 9.0% in 2017-2018 (p=0.01).

Bleeding After Cardiac Surgery Is Associated With an Increase in the Total Cost of the Hospital Stay.

BACKGROUND: Cardiac surgery results in complications for some patients that lead to a longer hospital stay and higher costs. This study identified the presurgery characteristics of patients that were associated with the cost of their hospital stay and estimated how much of that cost could be attributed to a bleeding event, defined as requiring 3 units or more of packed red blood cells or returning to the operating room for bleeding. We also identified the presurgery characteristics that were associated with the bleeding event. METHODS: This prospective cohort of patients (n = 1459) underwent cardiac surgery at 3 tertiary referral hospitals in Australia during 2014 and 2015. Clinical data included the variables held by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry. Cost data were collected as part of a state-level hospital data collection. RESULTS: Many of the baseline patient characteristics were associated with the total cost of cardiac surgery. After adjusting for these characteristics, the cost of cardiac surgery was 1.76 (confidence interval, 1.64-1.90) times higher for patients who had a bleeding event (P < .001), thus resulting in a median increase in costs (in Australian dollars) of $33,338 (confidence interval, $21,943-$38,415). Several baseline characteristics were strongly associated with a bleeding event. CONCLUSIONS: The impact of a bleeding event on the cost of cardiac surgery is substantial. This study identified a set of risk factors for bleeding that could be used to identify patients for discussion at the heart team level, where measures to minimize the risk of transfusion may be initiated.

Examination of a Proposed 30-day Readmission Risk Score on Discharge Location and Cost.

BACKGROUND: Readmissions cost an estimated $41 billion in the United States each year. To address this, a single institution recently developed a new risk model predictive of 30-day readmission after adult cardiac surgery. The purpose of this study is to validate and refine this new readmission risk model using a statewide database. METHODS: A total of 19,964 patients were analyzed using a statewide Society of Thoracic Surgeons database (2014-2017). The aforementioned multivariate model was replicated (model 1): race, hospital length of stay, chronic lung disease, operation type, and renal failure. Model 2 also included discharge location. Thirty-day readmission risk scores and low-risk (0%-10%), moderate-risk (10%-13%), and high-risk (≥13%) categories were calculated. RESULTS: The overall 30-day readmission rate was 11.1% with both models 1 and 2 predicting readmission (odds ratio, 1.09; 95% confidence interval, 1.08-1.11 vs odds ratio, 1.10; 95% confidence interval, 1.08-1.11). Statistically significant differences were observed across all risk categories in discharge location and total cost. For models 1 and 2, 86% of low-risk patients were discharged to home vs 66.9% and 42.9% of patients in high-risk groups, respectively (P < .001). The largest increases were observed with a hospice discharge location for both model 1 (from $37,930 to $89,285) and model 2 (from $37,930 to $89,230). CONCLUSIONS: Both risk models significantly predicted 30-day readmission in our multiinstitutional dataset, confirming the score is valid and a generalizable quality improvement tool. The addition of discharge location and total cost adds valuable information of the ongoing efforts to identify patients at high risk for readmission.

Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists.

BACKGROUND: Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry. METHODS: A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018. RESULTS: Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place. CONCLUSIONS: Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.

Ecocardiógrafo portátil para evaluación de pacientes con indicación de cirugía cardiovascular / Portable echocardiograph for evaluation of patients with indication for cardiovascular surgery

INTRODUCCIÓN: Este documento técnico se realiza a solicitud del Instituto Nacional de Salud del Niño - San Borja. A. Cuadro clínico: La cirugía cardiovascular se encuentra entre las intervenciones terapéuticas para el manejo de patologías cardiovasculares. Durante la cirugía es fundamental tener herramientas de imágenes como la ecocardiografía transesofágica para poder monitorear el procedimiento y medir la función cardiaca. Es ideal que este monitoreo se haga durante la cirugía, así como en el postoperatorio para valorar el éxito del procedimiento. Convencionalmente el ecocardiógrafo cuenta con una sala especial para el procedimiento, siendo este dispositivo de gran tamaño con movilización dificultosa a otras salas. Es por esto, que en los últimos años se han desarrollado ecocardiógrafos portátiles. B. Tecnología sanitaria: El ecocardiógrafo doppler portátil es un dispositivo que utiliza el ultrasonido para el diagnóstico de condiciones cardiacas que, a diferencia del ecocardiógrafo convencional, es liviano y funciona usualmente a batería. La simplicidad de uso, la disponibilidad para uso en cualquier sala, la facilidad de transporte y el costo relativamente bajo podrían ser beneficiosos para la rápida toma de decisiones clínicas. OBJETIVO: Evaluar la eficacia y seguridad, así como documentos relacionados a la decisión de cobertura del ecocardiógrafo portátil para monitoreo de pacientes con cirugía cardiovascular. METODOLOGÍA: Se realizó una búsqueda en las principales bases de datos bibliográficas: MEDLINE, LILACS, COCHRANE, así como en buscadores genéricos de Internet incluyendo Google Scholar y TRIPDATABASE. Adicionalmente, se hizo una búsqueda dentro de la información generada por las principales instituciones internacionales de ginecología y agencias de tecnologías sanitarias que realizan revisiones sistemáticas (RS), evaluación de tecnologías sanitarias (ETS) y guías de práctica clínica (GPC). RESULTADOS: No se identificaron ensayos clínicos aleatorizados, revisiones sistemáticas o evaluaciones económicas de la región. Se identificaron tres estudios observacionales comparativos, dos GPC, un consenso de expertos y una ETS. CONCLUSIONES: La evidencia con respecto al uso del ecocardiógrafo portátil es moderada. A partir de estudios comparativos, se evidencia que la precisión diagnóstica del ecocardiógrafo portátil es alta siendo mayor del 85% siendo el ecocardiógrafo convencional el estándar de oro. Además, se evidencia que el procedimiento se realiza en menor tiempo llevando a un menor tiempo de espera para los pacientes. Las guías de práctica clínicas inidentificadas, así como un consenso de expertos, recomiendan el uso de dispositivos portátiles, mencionando según sea conveniente se debe verificar los resultados con un ecocardiógrafo convencional. Una evaluación de tecnologías sanitarias considera al ecocardiógrafo portátil de beneficio para el control de paciente con cardiopatía establecida, resaltando que el dispositivo debe ser usado por personal capacitado en el procedimiento ya que la precisión diagnóstica es operador dependiente. No se encontraron evaluaciones económicas en la región acerca de la tecnología de interés.

Physician network position and patient outcomes following implantable cardioverter defibrillator therapy.

OBJECTIVE: To evaluate two novel measures of physician network centrality and their associations with implantable cardioverter defibrillator (ICD) procedure volume and health outcomes. DATA SOURCES: Medicare claims and the National Cardiovascular Data Registry data from 2007 to 2011. STUDY DESIGN: We constructed a national cardiovascular disease patient-sharing physician network and used network analysis to characterize physician network centrality with two measures: within-hospital degree centrality (number of connections within a hospital) and across-hospital degree centrality (number of connections across hospitals). The primary outcome was risk-adjusted 2-year case fatality. Hierarchical logistic regression estimated the effects of physician's within-hospital and across-hospital degree centrality on case fatality. We included 105 109 ICD therapy patients and 3474 ICD implanting physicians in our analyses. PRINCIPAL FINDINGS: After controlling for other physician and hospital characteristics, we observed greater risk-adjusted case fatality among patients treated by physicians in the highest across-hospital degree tertile compared to lowest tertile (OR [95% CI] = 1.10 [1.04-1.16], P = 0.001) and lowest tertile volume physicians compared with highest volume (OR [95% CI] = 0.90 [0.84-0.95], P < 0.001). Physician's within-hospital degree tertile was inversely associated with case fatality but not statistically significant. CONCLUSIONS: Degree centrality measures capture information independent of procedure volume and raise questions about the quality of physicians with networks that predict worse health outcomes.

Cardiac Surgery in HIV Patients: State of the Art.

The clinical status of HIV infection has changed dramatically with the introduction of combined antiretroviral therapy. Patients with HIV are now living long enough to be susceptible to chronic illnesses, such as coronary disease and nonischemic cardiomyopathy, which can be consequences of the combined antiretroviral therapy treatment itself. Cardiovascular diseases are a major source of morbidity and mortality in HIV-positive patients. Increasingly, such patients might be candidates for the full range of cardiac surgical interventions, including coronary bypass, valve surgery, and heart transplantation. There has been a shift from offering palliative procedures such as pericardial window and balloon valvuloplasty, to more conventional and durable surgical therapies in HIV-positive patients. We herein provide an overview of the contemporary outcomes of cardiac surgery in this complex and unique patient population. We review some of the ethical issues around the selection and surgical care of HIV-positive patients. We also discuss strategies to best protect the surgical treatment team from the risks of HIV transmission. Finally, we highlight the need for involvement of dedicated infectious disease professionals in a multidisciplinary heart team approach, aiming at the comprehensive care of these unique and complex patients.