Lifetime Management of Patients With Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement.

Aortic stenosis is the most common valvular disease. Surgical aortic valve replacement (SAVR) using mechanical valves has been the preferred treatment for younger patients, but bioprosthetic valves are gaining favour to avoid anticoagulation with warfarin. Transcatheter aortic valve replacement (TAVR) was approved in recent years for the treatment of severe aortic stenosis in intermediate- and low-risk patients as an alternative to SAVR. The longer life expectancy of these groups of patients might exceed the durability of the TAVR or SAVR bioprosthetic valves. Therefore, many patients need 2 or even 3 interventions during their lifetime. Because it has important implications on the feasibility of subsequent procedures, the decision between opting for SAVR or TAVR as the primary procedure requires thorough consideration by the heart team, incorporating patient preferences, clinical indicators, and anatomic aspects. If TAVR is favoured initially, selecting the valve type and determining the implantation level should be conducted, aiming for positive outcomes in the index intervention and keeping in mind the potential for subsequent TAVR-in-TAVR procedures. When SAVR is selected as the primary procedure, the operator must make choices regarding the valve type and the potential need for aortic root enlargement, with the intention of facilitating future valve-in-valve interventions. This narrative review examines the existing evidence concerning the lifelong management of severe aortic stenosis, delving into available treatment strategies, particularly emphasising the initial procedure's selection and its impact on subsequent interventions.

Six ways to maximize survey response rates: lessons from a medical school accreditation survey in a Canadian setting.

Background: Surveys are being increasingly used to gather feedback and study data in healthcare professions. However, it may be challenging to achieve high response rates in surveys administered to healthcare professionals. The aim of this paper is to report six strategies that contributed to a high response rate on the Independent Student Analysis at the University of Toronto (U of T), which can be applied to other surveys to achieve strong response rates amongst healthcare professionals. Methods: In 2019, as part of accreditation for the U of T MD Program, we conducted the Independent Student Analysis, a student-led survey examining a medical student's experience. We review and critically evaluate the factors that contributed to a robust response rate amongst one of the largest cohorts of medical students in Canada. Results: Among 1080 students in the MD program, we achieved an unprecedented response rate of 87.2%. Six factors were identified that most contributed to our high response rate, including: faculty support, student representation, eliciting participant feedback, creating protected time for completion, offering incentives, and generating awareness. Conclusions: Eliciting high survey response rates from medical learners can be challenging. However, with careful consideration of learner feedback and effective employment of the strategies discussed in this paper, medical school faculty may better engage students in survey completion, achieving higher response rates and gathering richer insight, which can be used to more effectively enact meaningful change amongst healthcare professionals.

Contexte: Les enquêtes auprès de professionnels de la santé sont de plus en plus utilisées pour recueillir et étudier des perspectives et des données, mais il peut s'avérer difficile d'obtenir des taux de réponse élevés. Cet article vise à présenter six stratégies qui ont permis de susciter une forte participation à l'enquête de l'Analyse indépendante des étudiants à l'Université de Toronto et qui peuvent être transposées à d'autres contextes de sondage auprès des professionnels du domaine.En 2019, dans le cadre du processus d'agrément du programme de doctorat en médecine de l'Université de Toronto, nous avons réalisé l'Analyse indépendante des étudiants, une enquête dirigée par les étudiants en médecine visant à examiner leur expérience. Nous passons en revue et évaluons de manière critique les facteurs qui ont contribué à l'atteinte d'un taux de réponse élevé auprès d'une des plus grandes cohortes d'étudiants en médecine au Canada. Résultats: Nous avons obtenu un taux de réponse sans précédent de 87,2 % parmi les 1 080 étudiants inscrits au programme de médecine. Les six facteurs qui ont le plus contribué à ce taux de réponse élevé sont : le soutien du corps professoral, la représentation des étudiants, leur participation à la conception de l'enquête, la création de plages horaires réservées pour remplir le questionnaire, l'offre d'incitatifs et la sensibilisation. Conclusions: Il peut être difficile de susciter une forte participation aux questionnaires chez les étudiants en médecine. Cependant, en considérant attentivement les commentaires des apprenants et en utilisant efficacement les stratégies présentées dans cet article, le corps professoral seront en mesure de mobiliser les étudiants à participer davantage aux enquêtes et de tirer profit de leur apport pour éclairer la promotion de changements pertinents chez les professionnels de la santé.

Social Deprivation and Post-TAVR Outcomes in Ontario, Canada: A Population-Based Study.

Background Transcatheter aortic valve replacement (TAVR)/intervention has become the standard of care for treatment of severe aortic stenosis across the spectrum of risk. There are socioeconomic disparities in access to TAVR. The impact of these disparities on postprocedural outcomes remains unknown. Our objective was to examine the association between neighborhood-level social deprivation and post-TAVR mortality and hospital readmission. Methods and Results We conducted a population-based retrospective cohort study of all 4145 patients in Ontario, Canada, who received TAVR from April 1, 2017, to March 31, 2020. Our co-primary outcomes were 1-year postprocedure mortality and 1-year postprocedure readmission. Using Cox proportional hazards models for mortality and cause-specific competing risk hazard models for readmission, we evaluated the relationship between neighborhood-level measures of residential instability, material deprivation, and concentration of racial and ethnic groups with post-TAVR outcomes. After multivariable adjustment, we found a statistically significant relationship between residential instability and postprocedural 1-year mortality, ranging from a hazard ratio of 1.64 to a hazard ratio of 2.05. There was a significant association between the highest degree of residential instability and 1-year readmission (hazard ratio, 1.23 [95% CI, 1.01-1.49]). There was no association between material deprivation and concentration of racial and ethnic groups with post-TAVR outcomes. Conclusions Residential instability was associated with increased risk for post-TAVR mortality, and the highest quintile of residential instability was associated with increased post-TAVR readmission. To reduce health disparities and promote an equitable health care system, further research and policy interventions will be required to identify and support economically and socially minoritized patients undergoing TAVR.

Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review.

Background: Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI. Methods: We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review. Results: We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access. Conclusions: This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.

Contexte: Bien que l'implantation valvulaire aortique par cathéter (IVAC) soit maintenant une option thérapeutique largement acceptée pour la prise en charge de la sténose aortique, les taux de réadmission des patients après cette intervention demeurent élevés. La réhospitalisation est associée à des résultats de santé défavorables pour les patients ainsi qu'à des coûts de soins de santé plus élevés, ce qui en fait une cible importante pour l'amélioration de la qualité des soins. Des stratégies de réduction des taux de réadmission après l'IVAC sont nécessaires, mais elles exigent de repérer les patients qui présentent des risques de réhospitalisation plus élevés. Notre revue systématique vise à cerner les facteurs prédictifs de réhospitalisation après l'intervention chez les patients admissibles à une IVAC. Méthodologie: Nous avons effectué une recherche exhaustive dans les bases de données MEDLINE, Embase et Cochrane Central Register of Controlled Trials (CENTRAL) pour trouver les articles publiés entre 2015 et aujourd'hui qui rapportent les facteurs de risque de réhospitalisation suite à une IVAC chez les adultes âgés de 70 ans et plus atteints de sténose aortique, avec une période de suivi d'au moins 30 jours. La qualité des études retenues a été évaluée à l'aide de l'échelle Newscastle-Ottawa. Les résultats sont présentés sous forme d'une revue narrative qualitative. Résultats: Nous avons retenu 49 études, réalisées auprès de 828 528 patients. La réhospitalisation après l'IVAC était fréquente, et les taux étaient variables (de 14,9 % à 54,3 % après un an). Les facteurs prédictifs de réhospitalisation les plus fréquents, déterminés 30 jours et un an après l'IVAC, étaient la fibrillation auriculaire, la maladie pulmonaire, la maladie rénale, le diabète, l'hémorragie menaçant le pronostic vital lors du séjour à l'hôpital, et l'approche par une voie non fémorale. Conclusions: La présente revue systématique nous a permis de caractériser les facteurs prédictifs les plus fréquents de réhospitalisation, 30 jours et un an après une IVAC, dont certaines affections concomitantes et certains facteurs potentiellement modifiables liés aux approches d'intervention et aux complications. Ces facteurs pourraient permettre de cibler les patients à risque élevé de réhospitalisation, qui seraient les plus susceptibles de bénéficier d'un soutien et d'un suivi accrus après une IVAC.

Assessing effective mask use by the public in two countries: an observational study.

OBJECTIVES: During the COVID-19 pandemic wearing a mask in public has been recommended in some settings and mandated in others. How often this advice is followed, how well, and whether it inadvertently leads to more disease transmission opportunities due to a combination of improper use and physical distancing lapses is unknown. DESIGN: Cross-sectional observational study performed in June-August 2020. SETTING: Eleven outdoor and indoor public settings (some with mandated mask use, some without) each in Toronto, Ontario, and in Portland, Oregon. PARTICIPANTS: All passers-by in the study settings. OUTCOME MEASURES: Mask use, incorrect mask use, and number of breaches (ie, coming within 2 m of someone else where both parties were not properly masked). RESULTS: We observed 36 808 persons, the majority of whom were estimated to be aged 31-65 years (49%). Two-thirds (66.7%) were wearing a mask and 13.6% of mask-wearers wore them incorrectly. Mandatory mask-use settings were overwhelmingly associated with mask use (adjusted OR 79.2; 95% CI 47.4 to 135.1). Younger age, male sex, Torontonians, and public transit or airport settings (vs in a store) were associated with lower adjusted odds of wearing a mask. Mandatory mask-use settings were associated with lower adjusted odds of mask error (OR 0.30; 95% CI 0.14 to 0.73), along with female sex and Portland subjects. Subjects aged 81+ years (vs 31-65 years) and those on public transit and at the airport (vs stores) had higher odds of mask errors. Mask-wearers had a large reduction in adjusted mean number of breaches (rate ratio (RR) 0.19; 95% CI 0.17 to 0.20). The 81+ age group had the largest association with breaches (RR 7.77; 95% CI 5.32 to 11.34). CONCLUSIONS: Mandatory mask use was associated with a large increase in mask-wearing. Despite 14% of them wearing their masks incorrectly, mask users had a large reduction in the mean number of breaches (disease transmission opportunities). The elderly and transit users may warrant public health interventions aimed at improving mask use.