Increased cardiovascular death rates in a COVID-19 low prevalence area.

The province of L'Aquila (Central Italy) was marginally affected by COVID-19 pandemic, but changes in health care seeking behaviors were noticed. The authors retrospectively analyzed de-identified data concerning all-cause and cardiovascular hospitalizations, cardiovascular acute phase treatments, and in-hospital cardiovascular deaths in the province of L'Aquila from January 1 to March 31, in 2020 and 2019. Incidence rate ratios (IRR) comparing 2020 and 2019 for admissions/procedures were calculated through Poisson regression. All-cause and cardiovascular mortality in the examined time windows was also assessed. Less all-cause (IRR 0.85, P < .001) and cardiovascular (IRR 0.73, P < .001) hospitalizations occurred in 2020 than in 2019. Less daily cardiovascular procedures were also performed (IRR: 0.74, P = .009). A disproportionate decrease in the number of procedures was observed in relation to cardiovascular hospitalizations in 2020 (-5.5%, P = .001). Unlike all-cause mortality, more in-hospital cardiovascular deaths occurred in March 2020 compared with March 2019 (+6.8%, P = .048).

Oral Health Status, Health Behaviour and Treatment Needs of Patients Undergoing Cardiovascular Surgery.

OBJECTIVE: The aim of the present study was to assess the oral health status and treatment needs of cardiovascular surgery patients. Second, the awareness of cardiovascular surgery patients regarding the association between oral health and heart disease was considered. METHODS: Assessment of oral health status, oral hygiene practices and treatment needs of 106 hospitalized patients in preparation for cardiovascular surgery. Patients were interviewed using a structured questionnaire designed for this study and oral examination was carried out by a dentist. RESULTS: The oral hygiene practices of the study cohort were not up to the standard. Patients' awareness of infective endocarditis was poor. Approximately 68% patients experienced dental caries as decayed teeth or missing teeth due to caries and filled teeth. The mean plaque index in the study group was 1.25. In this study cohort, the mean probing depth of periodontal pockets was 5.7±1.3, whereas the mean number of teeth with periodontal pockets > 6 mm was 0.5±0.9. A total of 84 (74.2%) of the patients required dental treatment. CONCLUSION: The principal finding in this study was that patients with heart disease had poor oral health. This study also highlights the importance of better interaction among all healthcare professionals to integrate oral health as part of comprehensive inpatient healthcare.

Oral health status, health behaviour and treatment needs of patients undergoing cardiovascular surgery

Abstract Objective: The aim of the present study was to assess the oral health status and treatment needs of cardiovascular surgery patients. Second, the awareness of cardiovascular surgery patients regarding the association between oral health and heart disease was considered. Methods: Assessment of oral health status, oral hygiene practices and treatment needs of 106 hospitalized patients in preparation for cardiovascular surgery. Patients were interviewed using a structured questionnaire designed for this study and oral examination was carried out by a dentist. Results: The oral hygiene practices of the study cohort were not up to the standard. Patients' awareness of infective endocarditis was poor. Approximately 68% patients experienced dental caries as decayed teeth or missing teeth due to caries and filled teeth. The mean plaque index in the study group was 1.25. In this study cohort, the mean probing depth of periodontal pockets was 5.7±1.3, whereas the mean number of teeth with periodontal pockets > 6 mm was 0.5±0.9. A total of 84 (74.2%) of the patients required dental treatment. Conclusion: The principal finding in this study was that patients with heart disease had poor oral health. This study also highlights the importance of better interaction among all healthcare professionals to integrate oral health as part of comprehensive inpatient healthcare.

Outcomes, risk factors and health burden of contrast-induced acute kidney injury: an observational study of one million hospitalizations with image-guided cardiovascular procedures.

BACKGROUND: Despite the use of low-osmolar contrast media that have significantly reduced the occurrence of severe adverse reactions, contrast-induced (CI) acute kidney injury (AKI) remains the third cause of AKI in hospitals. We sought to estimate the frequency of CI-AKI among hospitalized patients undergoing image-guided cardiovascular procedures, to quantify the effect of risk factors on the development of this complication and to assess relative organizational and economic burden in healthcare. METHODS: A retrospective cross-sectional population-based study using the extensive French hospital discharge database (PMSI) was carried out. Hospitalizations with image-guided cardiovascular procedures using a contrast media were identified in adults over a 2-year period (2012-2013). Suspected CI-AKI was defined as the presence, during hospitalization, of a diagnostic code of AKI (International Classification of Diseases, 10th revision [ICD-10] codes: N141, 142, N144, N990, N17, N19 or R392) or a code of renal replacement therapy procedure (Classification Commune des Actes Médicaux [CCAM] codes: JVJB001, JVJF002-005 and JVJF008) as creatinine criteria were not available. RESULTS: During 1,047,329 hospitalizations studied, 32,308 suspected CI-AKI were observed, yielding a frequency of 3.1 %. By multivariate analysis, factors that significantly increased the risk of suspected CI-AKI included cardiogenic shock (odds ratio [OR] = 20.5, 95 % confidence interval [95 % CI] [18.7; 22.5]), acute heart failure (OR = 2.5, 95 % CI [2.4; 2.6]) and chronic kidney disease (OR = 2.3, 95 % CI [2.2; 2.3]. Renal replacement therapy was initiated during 6,335 (0.6 %) hospitalizations. The mean length of stay and cost of hospitalizations associated with suspected CI-AKI was higher than in hospitalizations without suspected CI-AKI (20.5 vs 4.7 days, p < 0.00001 and €15,765 vs €3,352, p < 0.0001, respectively). CONCLUSIONS: This is the first large-scale population-based study to estimate frequency and health burden of suspected CI-AKI occurring after image-guided cardiovascular procedures, and the first available data in a French population. We showed that this iatrogenic complication remains of high concern despite prevention efforts and contrast media product improvement. From our results, suspected CI-AKI is associated with particularly high mortality, significantly extends hospitalizations, and leads to additional costs reaching a total of €200M per year.

Socioeconomic effects of surgical site infection after cardiac surgery in Japan.

PURPOSE: Surgical site infection (SSI) increases medical costs and prolongs hospitalization; however, there has been no multicenter study examining the socioeconomic effects of SSI after cardiovascular surgery in Japan. METHODS: A retrospective 1:1 matched, case-controlled study on hospital stay and health care expenditure after cardiovascular surgery was performed in four hospitals. Patients selected for the study had undergone coronary artery bypass grafting and/or valve surgery between April, 2006 and March, 2008. Data were obtained for 30 pairs of patients. RESULTS: The mean postoperative stay for the SSI group was 49.1 days, being 3.7 times longer than that for the non-SSI group. The mean postoperative health care expenditure for the SSI group was ¥ 2,763,000 (US$27,630), being five times higher than that for the non-SSI group. Charges for drug infusion and hospitalization for inpatient care were significantly higher for the SSI group than for the non-SSI group. The increased health care expenditure was mainly attributed to the cost of antibiotics and antimicrobial agents. CONCLUSION: SSI after cardiovascular surgery not only prolonged the length of hospital stay, but also increased medical expenditure. Thus, the prevention of SSI after cardiovascular surgery is of great socioeconomic importance.

Transcatheter closure of patent ductus arteriosus and atrial septal defect without on-site surgical backup: a two-year experience in an African community.

Congenital heart disease contributes significantly to the health burden of children in Nigeria. Interventions for congenital heart disease have been available in the developed world since the first report on device closure of patent ductus arteriosus (PDA) in 1967 by Porstmann. However, this did not start in Nigeria until October 2010. This study aimed to document the profiles of the patients who had undergone interventions for congenital heart diseases since the availability of the procedure, the challenges encountered, and the prospects associated with the interventions at the study site. All the patients referred to undergo interventions for congenital heart disease at the study center between October 2010 and 2012 were studied. The profile of the patient, including diagnosis at referral, indication for interventions, and interventions performed, were documented. The patients ranged in age from 3 to 62 years (mean age, 13.54 ± 17.7 years), and the male-to-female ratio was 1:3. The diagnosis at referral included PDA in 10 (83 %) of the 12 patients and secundum atrial septal defect in 2 patients (17 %). They all had transcatheter closure of the defects. Interventional procedures for congenital heart diseases currently are available locally, but the high degree of manpower training required, the cost, and the local availability of consumables are major factors limiting their use. Regional and international collaboration could be mutually beneficial.

Structural heart diseases interventional training in Canada.

Structural heart disease interventions have evolved into an important component of interventional cardiology fellowship programs worldwide. Given the complexity of such interventions, the breadth of knowledge needed for optimal patient selection and postprocedural management, and the skills to perform them efficiently, advanced training has become mandatory. Postgraduate medical training in Canada has always been on the cutting edge of new technology, and excellent care is provided to the increasing population of adult patients with congenital heart disease. The current survey sought to collect relevant information and assess the opinion of interventional cardiology program directors in Canada regarding training in structural interventions. Our study reports the approximate number of structural procedures performed by interventional cardiology fellows in Canadian interventional cardiology fellowship programs, the form of the structural training, and the suggestions of program directors who are actively trying to integrate structural training into interventional cardiology fellowship programs.

The costs of heart failure in Poland from the public payer's perspective. Polish programme assessing diagnostic procedures, treatment and costs in patients with heart failure in randomly selected outpatient clinics and hospitals at different levels of care: POLKARD.

BACKGROUND: Heart failure (HF) is a chronic disease of great clinical and economic significance for both the healthcare system and patients themselves. AIM: To determine the consumption of medical resources for treatment and care of HF patients and to estimate the related costs. METHODS: The study involved 400 primary care practices and 396 specialist outpatient clinics, as well as 259 hospitals at all reference levels. The sample was representative and supplemented with patient interview data. Based on the consumption of particular resources and the unit costs of services in 2011, costs of care for HF patients in Poland were estimated. Separate analyses were conducted depending on the stage of the disease (according to NYHA classification I-IV). The public payer's perspective and a one year time horizon were adopted. RESULTS: Direct annual costs of an HF patient's treatment in Poland may range between PLN 3,373.23 and 7,739.49 (2011), the main cost item being hospitalisation. The total costs for the healthcare system could be as high as PLN 1,703 million, which is 3.16% of the National Health Fund's budget (Ex. rate from 05.03.2012: 1 EUR = 4.14 PLN). CONCLUSIONS: The costs of treating heart failure in Poland are high; proper allocation of resources to diagnostic procedures and treatment may contribute to rationalisation of the relevant expenditure.

Health care costs related to out-of-hospital cardiopulmonary arrest in Japan.

OBJECTIVES: Although cost analyses for emergency care are essential, data on costs of care for out-of-hospital cardiopulmonary arrest (OHCA) are scarce. The present study aimed to analyze health care costs related to OHCA using a nationwide administrative database in Japan. METHODS: Using the Diagnosis Procedure Combination database in Japan, we identified OHCA patients who were transported to 779 emergency medical centres between July and December in 2008 and 2009. We assessed patient survival and discharge status, receipt of specific treatments, and costs of in-hospital care. RESULTS: A total of 21,750 OHCA patients were identified. Overall, 59.6% were males, and the average age was 70.3 years. Of them, 1394 (6.4%) resulted in death without attempted resuscitation after hospital arrival (Group A), 14,973 (69.0%) died on admission day despite resuscitation attempts (Group B), 3680 (17.0%) died at ≥2 days after admission despite resuscitation attempts (Group C), 785 (3.6%) survived and were discharged to home (Group D) and 873 (4.0%) survived and discharged to other than home (Group E). The median total costs were $434, $1735, $4869, $28,097 and $31,161 in Groups A to E, respectively. Positive survival status, longer hospital stay and receipt of specific treatments were significant predictors of higher total costs. After adjustment for these factors, higher age was associated with lower costs. CONCLUSIONS: The findings in the present study add further evidence to existing knowledge about healthcare costs related to OHCA.

Assessment of the effect on blood loss and transfusion requirements when adding a polyethylene glycol sealant to the anastomotic closure of aortic procedures: a case-control analysis of 102 patients undergoing Bentall procedures.

BACKGROUND: The use of CoSeal(®), a polyethylene glycol sealant, in cardiac and vascular surgery for prevention of anastomotic bleeding has been subject to prior investigations. We analysed our perioperative data to determine the clinical benefit of using polyethylene glycol sealant to inhibit suture line bleeding in aortic surgery. METHODS: From January 2004 to June 2006, 124 patients underwent aortic surgical procedures such as full root replacements, reconstruction and/or replacement of ascending aorta and aortic arch procedures. A Bentall procedure was employed in 102 of these patients. In 48 of these, a polyethylene glycol sealant was added to the anastomotic closure of the aortic procedure (sealant group) and the other 54 patients did not have this additive treatment to the suture line (control group). RESULTS: There were no significant between-group differences in the demographic characteristics of the patients undergoing Bentall procedures. Mean EuroSCORES (European System for Cardiac Operative Risk Evaluation) were 13.7 ± 7.7 (sealant group) and 14.4 ± 6.2 (control group), p = NS. The polyethylene glycol sealant group had reduced intraoperative and postoperative transfusion requirements (red blood cells: 761 ± 863 versus 1248 ± 1206 ml, p = 0.02; fresh frozen plasma: 413 ± 532 versus 779 ± 834 ml, p = 0.009); and less postoperative drainage loss (985 ± 972 versus 1709 ± 1302 ml, p = 0.002). A trend towards a lower rate of rethoracotomy was observed in the sealant group (1/48 versus 6/54, p = 0.07) and there was significantly less time spent in the intensive care unit or hospital (both p = 0.03). Based on hypothesis-generating calculations, the resulting economic benefit conferred by shorter intensive care unit and hospital stays, reduced transfusion requirements and a potentially lower rethoracotomy rate is estimated at €1,943 per patient in this data analysis. CONCLUSIONS: The use of this polymeric surgical sealant demonstrated improved intraoperative and postoperative management of anastomotic bleeding in Bentall procedures, leading to reduced postoperative drainage loss, less transfusion requirements, and a trend towards a lower rate of rethoracotomy. Hypothesis-generating calculations indicate that the use of this sealant translates to cost savings. Further studies are warranted to investigate the clinical and economic benefits of CoSeal in a prospective manner.

Progress towards a National Cardiac Procedure Database--development of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and Melbourne Interventional Group (MIG) registries.

Since the call for a National Cardiac Procedures Database in 2001, much work has been accomplished in both cardiac surgery and interventional cardiology in an attempt to establish a unified, systematic approach to data collection, defining a common minimum dataset pertinent to the Australian context, and instituting quality control measures to ensure integrity and privacy of data. In this paper we outline the aims of the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and the Melbourne Interventional Group (MIG) registries, and propose a comprehensive set of standardised data elements and their definitions to facilitate transparency in data collection, consistency between these and other data sets, and encourage ongoing peer-review. The aims are to improve outcomes for patients by determining key performance indicators and standards of performance for hospital units, to allow estimation of procedural risks and likelihood of outcomes for patients, and to report outcomes to relevant stake-holders and the public.

Stratification of complexity improves the utility and accuracy of outcomes analysis in a Multi-Institutional Congenital Heart Surgery Database: Application of the Risk Adjustment in Congenital Heart Surgery (RACHS-1) and Aristotle Systems in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database.

Quality-of-care evaluation must take into account variations in "ase mix."This study reviewed the application of two case-mix complexity-adjustment tools in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database: the Aristotle Basic Complexity (ABC) score and the Risk Adjustment in Congenital Heart Surgery (RACHS-1) method. The 2006 STS Congenital Heart Surgery Database Report, the first STS report to incorporate both methods, included 45,635 operations from 47 centers. Each operation was assigned an ABC score in a range from 1.5 (lowest complexity) to 15 (highest complexity), an ABC level in a range from 1 (lowest complexity) to 4 (highest complexity), and a RACHS-1 category in a range from 1 (lowest risk) to 6 (highest risk). The overall discharge mortality was 3.9% (1,222/31,719 eligible cardiac index operations). Of the eligible cardiac index operations, 85.8% (27,202/31,719) were eligible for analysis by the RACHS-1 method, and 94.0% (29,813/31,719) were eligible for analysis by the ABC approach. With both RACHS-1 and ABC, as complexity increases, discharge mortality also ncreases. The ABC approach allows classification of more operations, whereas the RACHS-1 discriminates better at the higher end of complexity. Complexity stratification is a useful method for analyzing the impact of case mix on pediatric cardiac surgical outcomes. Both the RACHS-1 and ABC methods facilitate complexity stratification in the STS database.

Clinical impact of early clopidogrel discontinuation following acute myocardial infarction hospitalization or stent implantation: analysis in a nationally representative managed-care population.

OBJECTIVES: To evaluate the association between discontinuation of clopidogrel therapy and risk of acute myocardial infarction (AMI) hospitalization or cardiac revascularization in a nationally-representative patient population following hospitalization for an AMI or coronary stent insertion. RESEARCH DESIGN AND METHODS: This observational cohort study was performed using data on patients from the PharMetrics Anonymous Patient-Centric Database who were hospitalized for an AMI or coronary stent insertion and subsequently treated with clopidogrel. Cox proportional hazard modeling was used to evaluate the association between clopidogrel discontinuation prior to 1 year post-initial AMI hospitalization and the primary endpoint of repeat AMI hospitalization or coronary intervention defined as percutaneous coronary intervention (PCI) with or without stent, or coronary artery bypass graft (CABG). MAIN OUTCOME MEASURES: The main outcome for this study was AMI hospitalization or coronary intervention defined as PCI with or without stent placement or CABG. RESULTS: A total of 31 835 patients were included in the analyses. Patients were predominantly male and the average patient age was approximately 60 years. After controlling for baseline patient characteristics and follow-up time, discontinuation of clopidogrel was associated with a significantly higher rate of hospitalization for AMI or coronary intervention (HR 1.34, 95% CI 1.22-1.44). CONCLUSION: Within a population of ACS patients drawn from a database of 85 US health plans, clopidogrel discontinuation within 1 year following hospitalization for AMI or stent placement is associated with an increased risk of AMI hospitalization or coronary intervention. The results of this study should be interpreted within the context of observational research, which does not address cause and effect relationships.

[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]. / Komplexfallpauschalen in der Herzchirurgie--ein Modellprojekt zur Frührehabilitation.

BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

Effect of hospital ownership status and payment structure on the adoption and use of drug-eluting stents for percutaneous coronary interventions.

BACKGROUND: The impact of the use of drug-eluting stents in percutaneous coronary intervention (PCI) on cardiac care is still uncertain. We examined the influence of systemic factors, such as hospital ownership status, organizational characteristics and payment structure, on the use of drug-eluting stents in PCI and the effect on cardiac surgery volume. METHODS: We conducted a cross-sectional analysis of drug-eluting stent use in 12 993 patients undergoing PCI with stenting (drug-eluting or bare-metal) and time-series regression analyses of the monthly number of cardiac surgery and PCI procedures performed using data collected from 1998 to 2004 at 13 public and private hospitals in the Emilia-Romagna region of Italy. RESULTS: Public hospitals used drug-eluting stents more selectively than private hospitals, targeting the new device to patients at high risk of adverse events. The time-series regression analyses showed that the number of PCI procedures performed per year increased during this period, both in public (slope coefficient 36.4, 95% confidence interval [CI] 30.2 to 43.1) and private centres (slope coefficient 6.4, 95% CI 3.1 to 9.2 ). Concurrently, there was a reduction in the number of isolated coronary artery bypass graft (CABG) surgeries, although the degree of change was higher in public than in private hospitals (coefficient -16.1 v. -6.2 respectively ). The number of CABG procedures associated with valve surgery decreased in public hospitals (coefficient -5.0, 95% CI -6.1 to -3.8) but increased in private hospitals (coefficient 4.1, 95% CI 2.0 to 6.1). INTERPRETATION: Public and private hospitals behaved differently in adopting drug-eluting stents and in using PCI with drug-eluting stents as a substitute for surgical revascularization.

Hypoplastic left heart syndrome in US military family members: trends in intervention, survival, and prevalence.

INTRODUCTION: Hypoplastic left heart syndrome was uniformly fatal until the 1980s but now has survival approaching 70% to age 5 due to treatment advances. The current study was undertaken to examine trends in the intervention rate, survival, and prevalence of hypoplastic left heart syndrome among US military family members. We hypothesized that increased rates of intervention and survival would produce a demonstrable increase in prevalence in this population. METHODS: This was a retrospective review of administrative data. Central databases contain records from Army hospital admissions since 1972, all military hospital admissions since 1989, outpatient visits since 2000, and civilian bills to the military system since 2000. Patients with an instance of the relevant diagnosis (code 746.7) were included and all of their data records reviewed. Patients with incompatible diagnoses or survival were excluded. RESULTS: There were 366 patients identified, 63 born in the 1980s, 155 in the 1990 s, and 148 after 2000. The rate of intervention increased from 54% in the 1990 s to 97% in the 2000s (P < .001). Five-year survival increased markedly between the 1980s and the 1990 s. For patients born since 2000 and undergoing intervention, survival was 66% to 21 months (95% confidence interval 56-75%). Prevalence at birth in military hospitals was 1.4 per 10,000 with no significant trend over time. Prevalence among inpatients other than at birth increased from 0.4 to 15 per 10,000 between 1989 and 2005 (r(2) = 0.92, P < .001). CONCLUSIONS: The rates of intervention and survival of patients with hypoplastic left heart syndrome have increased dramatically over the past 15 years. This has resulted in a demonstrable increase in prevalence among the beneficiary population. Future study focused on this cohort could detail their healthcare needs and demonstrate the effect of hypoplastic left heart syndrome on the family and its growing impact on the military healthcare system.