Developing a mitral valve center of excellence.

PURPOSE OF REVIEW: Despite the proven superiority of mitral repair over replacement for degenerative mitral disease, mitral valve replacement remains common. Guidelines now recommend referral of patients, particularly those whom are asymptomatic, to valve centers of excellence, although criteria that define such centers remain to be established. The purpose of this review is to define the structure of a mitral center of excellence and to review current clinical outcomes which are possible in such a center. RECENT FINDINGS: Recently, American College of Cardiology/American Heart Association as well as the European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines define mitral centers of excellence as either centers in which the likelihood of successful and durable repair exceeds 95% and with an operative mortality risk of less than 1% (American College of Cardiology/American Heart Association definition) or centers with high repair rates, low operative mortality, and a record of durable results (European Society of Cardiology/European Association of Cardiothoracic Surgery definition). There is however less clarity about the structure and function of a center that achieves these outcomes. SUMMARY: The importance of centers of excellence in mitral valve surgery are now well recognized, and this review will highlight the key components and outcomes of an established mitral valve reference center.

The epidemiology of heart failure in adults with congenital heart disease.

The impact of lifelong exposure to myocardial dysfunction in populations with congenital heart disease (CHD) is becoming increasingly recognized. Most children born with CHD now reach adulthood and the long-term sequelae of treatment are contributing to substantial comorbidity. The combination of structural changes present at birth with changes resulting from cardiac surgery can result in heart failure. This article reports on the current state of knowledge on the epidemiology of heart failure in this patient population.

Using Dashboard Technology and Clinical Decision Support Systems to Improve Heart Team Efficiency and Accuracy: Review of the Literature.

AIM: This review aimed to provide a comprehensive overview of the current state of evidence for the use of clinical dashboards and clinical decision support systems (CDSS) in multidisciplinary teams. METHODS: A literature search was performed for the dates 2004-2014 on CINAHL, Medline, Embase, and Cochrane Library. A citation search and a hand search of relevant papers were also conducted. RESULTS: (One hundred and twelve full text papers were retrieved of which 22 were included in the review.) There was considerable heterogeneity in setting, users, and indicators utilized. Information on usability and human-computer interaction was thoroughly reviewed. There was evidence that dashboards were associated with improved care processes when end-user input was incorporated and information was concurrent, pertinent and intuitive. CONCLUSION: There is some evidence that implementing clinical dashboards and/or CDSS that provide immediate access to current patient information for clinicians can improve processes and patient outcomes.

The Role of the Syncope Management Unit.

Syncope is a common symptom, experienced by 15% of persons less than 18 years old and up to 23% of elderly nursing home residents, so it is important to consider optimizing strategies for the management of these patients. The strategy selected will inevitably differ from place to place. However, an organized structure offers more cost-effective care. This article discusses possible health care delivery models for syncope management and reviews the current status of the organization of syncope care, to show the value of a multidisciplinary approach to the organized management of patients with syncope.

Does in-patient ECG monitoring have an impact on medical care in chronic heart failure patients?

BACKGROUND: Heart failure patients' management in non-intensive care units might be improved by telemetry monitoring. However, telemetry adds the cost and evidence of this effectiveness is not available. AIM: To evaluate the utility of the ECG monitoring in chronic heart failure patients admitted to a non-intensive care unit. METHODS: A prospective analysis of the utility of telemetry in 711 patients admitted to a Heart Failure Unit from March 1996 to September 1997. RESULTS: One hundred and ninety-nine patients underwent telemetry; 108 telemetry findings were recorded, in 35% of NYHA class II, in 46% in NYHA class III-IV and 43% in unstable patients. Reasons for telemetry were: known arrhythmia (n=82), electrolytes disturbances (n=20), atrial fibrillation (n=12), symptoms (n=48), i.v. dobutamine (n=13), drugs control (n=16), devices control (n=8). Crossing reasons for telemetry and detected events we had, respectively, 63, 11, 2, 17, 5, 6, and 0 telemetry findings. Treatment was guided by telemetry results in only 33 cases (respectively in 18, 0, 4, 5, 5, 1, and 0 cases). Physicians perceived telemetry as unhelpful in 30% of cases; as helpful in 70%. The percentage of inutility, usefulness with and without related medical intervention were similar between stable and unstable patients (30, 18, 51% and 31, 15, 54%, respectively). CONCLUSION: In a heart failure unit ECG monitoring is mostly used in severe and unstable patients. However, medical decisions are rarely guided by the telemetry findings. The usefulness of telemetry might be underestimated because one of the uncounted results might be the avoidance of inappropriate intervention.

Integrated management of cardiac failure: the cardiac failure clinic.

The prevalence of the risk factors and the risk of cardiac failure are both increasing in China. This might be the consequence of the changes of the life conditions (emigration to the urban areas, changes in the diet and life style, lack of physical exercise, etc.). The wide range of clinical presentations of cardiac failure (acute or chronic) and of therapeutic approaches (medical or surgical) makes necessary the integration within the same structure of the various experts involved in the diagnosis and the treatment of cardiac diseases. Technologic and human resources required to offer all the options represent a multifaceted commitment which should be focused optimally in dedicated centers. In these centers, collaboration should replace competition between the medical and the surgical cardiac specialists. Development of team work should permit to optimize the cost efficacy of the treatments. Most of all, such a structure will facilitate the translation of innovative therapies between the research centers and clinical facilities.

Evaluation of a clinical decision support system for glucose control: impact of protocol modifications on compliance and achievement of glycemic targets.

Treating hyperglycemia may improve patient outcome, but is a clinical challenge. Three variations of a computerized insulin protocol were compared with regard to protocol compliance and achievement of glucose target levels. In group 1, the existing protocol was applied, in group 2 the protocol was modified to account for decreasing glucose values; group 3 had a higher threshold for initiating insulin, wider glucose target ranges, and included instructions to regulate glucose around mealtimes. From July 28, 2008 until February 1, 2010, data from 1255 patients admitted to our Intensive Cardiac Care Unit with at least 2 glucose measurements were analyzed. Mean age was 64 +/- 15 years, 66% were male, 21% had diabetes. Groups 1 to 3 included 269, 814, and 142 patients, respectively. Protocol compliance in group 2 was lower with 44% of the glucose measurements performed on time versus 51% in group 1 (P < 0.001), and insulin was dosed correctly in 57% versus 67% (P < 0.001). In group 3, compliance increased, 52% of the measurements were done on time, and insulin was dosed correctly in 71%. Average glucose levels increased in group 3 due to a higher threshold for starting insulin and a wider target range: 70% (group 1), 66% (group 2), and 61% (group 3) had an average glucose of <8 mmol/L (P < 0.001). Also, we observed a decreasing trend in incidence of hypoglycemia and reporting of noncompliance. Further improvements in glucose measurement technology and protocols are needed to optimally treat hyperglycemia in the Intensive Cardiac Care Unit.