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1.
JTCVS Open ; 16: 509-521, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-38204725

RESUMO

Objective: The study objective was to examine the association between hospital processes of care and failure to rescue in a diverse, multi-institutional cardiac surgery network. Methods: Failure to rescue was defined as an operative mortality after 1 or more of 4 complications: prolonged ventilation, stroke, renal failure, and unplanned reoperation. Society of Thoracic Surgeons data from 20,950 consecutive patients in the Columbia HeartSource network who underwent 1 of 7 cardiac operations-coronary artery bypass grafting, aortic valve replacement ± coronary artery bypass grafting, mitral valve repair or replacement ± coronary artery bypass grafting-were analyzed to calculate failure to rescue rates. Hospital-specific characteristics were ascertained by survey method. Multivariable mixed-effects logistic models assessed the association of these hospital characteristics with failure to rescue while adjusting for patient-related factors known to be associated with mortality. Results: Failure to rescue rates at affiliate hospitals ranged from 5.45% to 21.74% (median, 12.5%; interquartile range, 6.9%). When controlling for Society of Thoracic Surgeons-predicted risk of mortality with hospital as a random effect, 4 hospital characteristics were found to be associated with lower failure to rescue rates; the presence of cardiac-trained anesthesiologists (odds ratio, 0.41; CI, 0.31-0.55, P < .001), availability of extracorporeal membrane oxygenation mechanical circulatory support (odds ratio, 0.41; CI, 0.31-0.54, P < .001), ratio of intensive care unit beds to intensivists (odds ratio, 0.87; CI, 0.76-0.99, P = .039), and total number of intensive care unit beds (odds ratio, 0.97; CI, 0.96-0.99, P = .002). Conclusions: In a diverse multi-institutional cardiac surgical network, we were able to identify specific hospital processes of care associated with failure to rescue, even when adjusting for patient-related predictors of operative mortality.

2.
Struct Heart ; 5(2): 168-179, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-35378800

RESUMO

The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD. Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.

3.
J Thorac Cardiovasc Surg ; 162(1): 56-67.e44, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31982124

RESUMO

OBJECTIVE: Recent single-center and experimental data suggested greater adverse cardiac events for patients undergoing aortic valve replacement (AVR) in the morning (AM) versus the afternoon (PM). However, previous studies in patients undergoing coronary artery bypass grafting (CABG) have found no similar time-related difference. We examined the impact of AM versus PM operative time on surgical outcomes of CABG and AVR in a diverse, multi-institutional cardiac surgery network between January 2008 and September 2018. METHODS: The AM group included patients whose surgery start time was between 6:30 and 9 AM, whereas noon to 2:30 PM was considered PM (8901 AM/1962 PM) for CABG and (2598 AM/617 PM) for AVR. Because of imbalances in sample size, risk factors, and Society of Thoracic Surgeons predicted risk between groups, propensity score matching using all baseline characteristics was used to create 2 well-matched patient groups whose outcomes were compared. RESULTS: After propensity score matching, there was no difference in mortality, stroke, prolonged ventilation, renal failure, deep sternal wound infection, reoperation, myocardial injury, atrial fibrillation, or readmission between AM and PM groups for both isolated CABG and AVR. However, there were mixed differences noted in intensive care unit length of stay, postoperative length of stay, blood product use, and crossclamp time. Findings were stable when accounting for site and physician effects, whereas subgroup analyses showed similar findings in the elective, diabetic, Hispanic, and off-pump patient populations. CONCLUSIONS: There were no differences in operative mortality nor in major morbidity between well-matched AM and PM patients undergoing either CABG or AVR.


Assuntos
Valva Aórtica/cirurgia , Ritmo Circadiano , Ponte de Artéria Coronária/métodos , Implante de Prótese de Valva Cardíaca/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
4.
Catheter Cardiovasc Interv ; 84(6): 859-67, 2014 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-24760495

RESUMO

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly available therapy for the management of aortic stenosis in higher risk populations. Beyond addressing the procedural challenges, centers must attend to the unique requirements of developing TAVR programs from referral to follow-up. AIM: The aim of this article is to outline the recommendations for best practice for program development from centers with early and extensive experience. RECOMMENDATIONS: The guideline-recommended Heart Team approach requires interdisciplinary agreements, delineation of roles and responsibilities, and the development of the role of the TAVR Coordinator. To support appropriate case selection, the screening and evaluation must be organized in a comprehensive clinic visit. In addition to the multimodality imaging tests, the assessment of functional status and frailty is pivotal to the eligibility decision. Throughout the TAVR trajectory, careful attention must be afforded to the integration of geriatric best practices. Pre-procedure care requires patient and family education to manage expectations and facilitate early discharge planning. Peri-procedural care planning, including equipment requirements, monitoring protocols, and emergency intervention agreements, contributes to procedural success. The aims of post-procedure care are to monitor the recovery, facilitate the rapid return to baseline status, and optimize length of stay. TAVR programs require data management strategies to facilitate and monitor program growth, support program evaluation, and meet the requirements for submission to national registries. CONCLUSION: TAVR represents a paradigm shift in the management of structural heart disease. Programmatic success and patient outcomes depend on the development of a comprehensive and collaborative program tailored to TAVR.


Assuntos
Estenose da Valva Aórtica/terapia , Benchmarking/normas , Cateterismo Cardíaco/normas , Implante de Prótese de Valva Cardíaca/normas , Estenose da Valva Aórtica/diagnóstico , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Comportamento Cooperativo , Diagnóstico por Imagem/normas , Definição da Elegibilidade/normas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Comunicação Interdisciplinar , Equipe de Assistência ao Paciente/normas , Valor Preditivo dos Testes , Desenvolvimento de Programas/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Resultado do Tratamento
5.
JACC Cardiovasc Interv ; 5(9): 974-81, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22995885

RESUMO

OBJECTIVES: This study sought to evaluate the impact of frailty in older adults undergoing transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis. BACKGROUND: Frailty status impacts prognosis in older adults with heart disease; however, the impact of frailty on prognosis after TAVR is unknown. METHODS: Gait speed, grip strength, serum albumin, and activities of daily living status were collected at baseline and used to derive a frailty score among patients who underwent TAVR procedures at a single large-volume institution. The cohort was dichotomized on the basis of median frailty score into frail and not frail groups. The impact of frailty on procedural outcomes (stroke, bleeding, vascular complications, acute kidney injury, and mortality at 30 days) and 1-year mortality was evaluated. RESULTS: Frailty status was assessed in 159 subjects who underwent TAVR (age 86 ± 8 years, Society of Thoracic Surgery Risk Score 12 ± 4). Baseline frailty score was not associated with conventionally ascertained clinical variables or Society of Thoracic Surgery score. Although high frailty score was associated with a longer post-TAVR hospital stay when compared with lower frailty score (9 ± 6 days vs. 6 ± 5 days, respectively, p = 0.004), there were no significant crude associations between frailty status and procedural outcomes, suggesting adequacy of the standard selection process for identifying patients at risk for periprocedural complications after TAVR. Frailty status was independently associated with increased 1-year mortality (hazard ratio: 3.5, 95% confidence interval: 1.4 to 8.5, p = 0.007) after TAVR. CONCLUSIONS: Frailty was not associated with increased periprocedural complications in patients selected as candidates to undergo TAVR but was associated with increased 1-year mortality after TAVR. Further studies will evaluate the independent value of this frailty composite in older adults with aortic stenosis.


Assuntos
Estenose da Valva Aórtica/terapia , Cateterismo Cardíaco/efeitos adversos , Avaliação Geriátrica , Implante de Prótese de Valva Cardíaca/efeitos adversos , Atividades Cotidianas , Injúria Renal Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Biomarcadores/sangue , Cateterismo Cardíaco/mortalidade , Distribuição de Qui-Quadrado , Comorbidade , Feminino , Idoso Fragilizado , Marcha , Força da Mão , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemorragia/etiologia , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Cidade de Nova Iorque , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Albumina Sérica/análise , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Doenças Vasculares/etiologia
6.
Clin Cardiol ; 35(5): 307-14, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22331630

RESUMO

BACKGROUND: In the transcatheter aortic valve replacement era, characterization of functional status in older adults with aortic stenosis (AS) is essential. Gait speed (GS) is emerging as a marker of frailty and predictor of outcomes in older adults undergoing cardiovascular intervention. The objective of this study was to delineate the prevalence of slow GS, evaluate the association of GS with factors used in standard cardiovascular assessments, and evaluate the association of GS with dependence in activities of daily living (ADLs) in older adults with AS. HYPOTHESIS: We hypothesized that gait speed would not be associated with clinical factors, but would be associated with ADLs. METHODS: We evaluated GS, ADLs dependence, and Society of Thoracic Surgery score along with clinical and functional assessments in 102 older adults with AS being evaluated for transcatheter valve. Gait speed <0.5 m/s was considered slow, and GS ≥0.5 m/s was considered preserved. We assessed the association of covariates with GS as well as with ADLs dependence. RESULTS: Median GS was 0.37 m/s (interquartile range, 0.0-0.65 m/s). Sixty-four (63%) subjects had slow GS. Of commonly employed clinical covariates, only prior coronary intervention and serum albumin were weakly associated with GS. However, GS was independently associated with ADLs dependence (Odds ratio: 1.52 [1.21-1.91] for every 0.1 m/s decrease in GS; P = 0.0003). CONCLUSIONS: Although the prevalence of slow GS in a population of elderly patients with severe AS being screened for transcatheter valve was high, there were only weak associations between GS and other risk stratifying tools. The strong association between GS and dependent functional status suggests that assessment of gait speed is a useful, objectively measurable, risk stratification tool in this population.


Assuntos
Atividades Cotidianas , Estenose da Valva Aórtica/fisiopatologia , Marcha/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Masculino , Prevalência , Estudos Prospectivos
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