RESUMO
Infectious endocarditis is a highly morbid infection that requires coordination of care across medical and surgical specialties, often through the use of a multidisciplinary team model. Multiple studies have demonstrated that such conferences can improve clinical outcomes. However, little is known about physicians' impressions of these groups. We surveyed 126 (response rate of 30%) internal medicine, infectious diseases, cardiology, and cardiac surgery providers 1 year after the implementation of an endocarditis team at the University of Michigan. Ninety-eight percent of physicians felt that the endocarditis team improved communication between specialties. Additionally, over 85% of respondents agreed that the group influenced diagnostic evaluation, reduced management errors, increased access to surgery, and decreased in-hospital mortality for endocarditis patients. These results suggest that multidisciplinary endocarditis teams are valued by physicians as a tool to improve patient care and serve an important role in increasing communication between providers.
Assuntos
Atitude do Pessoal de Saúde , Endocardite , Equipe de Assistência ao Paciente , Médicos/psicologia , Humanos , Comunicação Interdisciplinar , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of aortic stenosis in patients at intermediate, high, and extreme risk for mortality from SAVR. We examined recent trends in aortic valve replacement (AVR) in Michigan. METHODS: The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC) database was used to determine the number of SAVR and TAVR cases performed from January 2012 through June 2017. Patients were divided into low, intermediate, high, and extreme risk groups based on STS predicted risk of mortality (PROM). TAVR patients in the MSTCVS-QC database were also matched with those in the Transcatheter Valve Therapy Registry to determine their Heart Team-designated risk category. RESULTS: During the study period 9517 SAVR and 4470 TAVR cases were performed. Total annual AVR volume increased by 40.0% (from 2086 to 2920), with a 13.3% decrease in number of SAVR cases (from 1892 to 1640) and a 560% increase in number of TAVR cases (from 194 to 1280). Greater than 90% of SAVR patients had PROM ≤8%. While >70% of TAVR patients had PROM ≤ 8%, they were mostly designated as high or extreme risk by a Heart Team. CONCLUSIONS: During the study period, SAVR volume gradually declined and TAVR volume dramatically increased. This was mostly due to a new group of patients with lower STS PROM who were designated as higher risk by a Heart Team due to characteristics not completely captured by the STS PROM score.
Assuntos
Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Masculino , Michigan , Risco , Substituição da Valva Aórtica Transcateter/métodos , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/tendênciasRESUMO
BACKGROUND: Prior cardiac surgery (PCS) can complicate the presentation and management of patients with type A acute aortic dissection (TAAAD). This report from the International Registry of Acute Aortic Dissection examines this hypothesis. METHODS AND RESULTS: A total of 352 of 2196 patients with TAAAD (16%) enrolled in the International Registry of Acute Aortic Dissection had cardiac surgery before dissection, including coronary artery bypass grafting (34%), aortic or mitral valve surgery (36%), aortic surgery (42%), and other cardiac surgery (16%). Those with PCS were older, had a higher frequency of diabetes mellitus, hypertension, and atherosclerosis, and presented later from symptom onset to hospital presentation and diagnosis (all P<0.05). In-hospital mortality was significantly higher for PCS patients (34% versus 23%; P<0.001). Five-year mortality was independently predicted by PCS (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.05-3.95), age >70 years (HR, 2.65; 95% CI, 1.40-5.05), medical management (HR, 5.10; 95% CI, 2.43-10.71), distal communication (HR, 2.64; 95% CI, 1.35-5.14), and coma (HR, 9.50; 95% CI, 2.05-44.05). Among patients with PCS, in-hospital (43% medical versus 30% surgical; P=0.033) and intermediate-term mortality was higher in patients with medical versus surgical management. Propensity-matched analysis revealed significant increase in mortality with medical management, but not with PCS. CONCLUSIONS: PCS delays presentation, diagnosis, and treatment of TAAAD and is an important adverse risk factor for early and intermediate-term mortality. This effect may be because of increased medical management in this patient population.
Assuntos
Aneurisma Aórtico/mortalidade , Dissecção Aórtica/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Internacionalidade , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Doença Aguda , Idoso , Dissecção Aórtica/diagnóstico , Aneurisma Aórtico/diagnóstico , Procedimentos Cirúrgicos Cardíacos/tendências , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
With increasing specialization within the field of cardiac surgery and a positive relationship between case volume and surgical outcomes in many areas, the concept of dedicated aortic surgeons performing acute type A aortic dissection (ATAAD) repair was investigated. From 1996 to 2014, 436 patients underwent open surgical repair of an ATAAD and were subsequently divided based on surgeon subspecialization, aortic-surgeon (AS, n = 401) vs non-aortic-surgeon (NAS, n = 35). Each aortic surgeon performed an average of 13 ATAAD repair operations per year. Preoperative comorbidities were similar between groups. Intraoperatively, the AS group had 36% aortic root replacement vs 23% in the NAS group, P = 0.12, and 36% zone 1/2/3 arch replacement vs 26% in the NAS group, P = 0.20). Postoperatively, the AS group had significantly better outcomes, including intraoperative mortality (1.2% vs 5.7%), 30-day mortality (6.5% vs 17%), and composite outcomes (23% vs 46%). Multivariable logistic regression showed NAS was a risk factor for 30-day mortality with an odds ratio (OR) of 4.4 (P = 0.03), as were COPD (OR = 4.0, P = 0.046) and cardiogenic shock (OR = 13.4, P < 0.0001). The 10-year survival was 66% in the AS group vs 46% in the NAS group, P = 0.02. NAS (HR = 2.2), Age (hazard ratio (HR) = 1.05), COPD (HR = 1.96), acute stroke (HR = 3.0), and New York Heart Association class III or IV (HR = 1.75) were significant risk factors for long-term mortality. Managing ATAAD by subspecialized aortic surgeons resulted in improved short- and long-term outcomes. Our specialty could consider ATAAD repair by high-volume aortic surgeons for better patient outcomes.
RESUMO
BACKGROUND: Infectious endocarditis is associated with substantial in-hospital mortality of 15%-20%. Effective management requires coordination between multiple medical and surgical subspecialties, which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality. METHODS: The multidisciplinary endocarditis team was formed in May 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control utilizing propensity matching. RESULTS: Between June 2018 and June 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria-definite endocarditis and at least 1 American Heart Association indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1, 2014, and June 30, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (P < .0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; P = 0.12). Propensity score matching demonstrated similar results. CONCLUSIONS: Implementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications, in the presence of notable differences between the 2 studied cohorts. In conjunction with previous studies demonstrating their effectiveness, these data support the idea that widespread adoption of endocarditis teams in North America could improve outcomes for this patient population.
Assuntos
Endocardite Bacteriana/cirurgia , Equipe de Assistência ao Paciente , Adulto , Idoso , Endocardite Bacteriana/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de PropensãoRESUMO
Over the last several years multiple studies, primarily from European centers have demonstrated the clinical and outcomes benefits of multidisciplinary endocarditis teams. Despite this literature, adoption of this approach to patient care has been slower in the United States. While there is literature outlining the optimal composition of an endocarditis team, there is little information to guide providers as they attempt to transform practice from a fragmented, disjointed process to an efficient, collaborative care model. In this review, the authors will outline the steps they took to create and implement a successful multidisciplinary endocarditis team at the University of Michigan. In conjunction with existing data, this piece can be used as a resource for clinicians seeking to improve the care of patients with endocarditis at their institutions.
RESUMO
Infectious endocarditis is a highly morbid disease with approximately 43,000 cases per year in the United States. The modified Duke Criteria have poor sensitivity; however, advances in diagnostic imaging provide new tools for clinicians to make what can be an elusive diagnosis. There are a number of risk stratification calculators that can help guide providers in medical and surgical management. Patients who inject drugs pose unique challenges for the health care system as their addiction, which is often untreated, can lead to recurrent infections after valve replacement. There is a need to increase access to medication-assisted treatment for opioid use disorders in this population. Recent studies suggest that oral and depo antibiotics may be viable alternatives to conventional intravenous therapy. Additionally, shorter courses of antibiotic therapy are potentially equally efficacious in patients who are surgically managed. Given the complexities involved with their care, patients with endocarditis are best managed by multidisciplinary teams.
Assuntos
Antibacterianos/administração & dosagem , Endocardite/diagnóstico , Endocardite/terapia , Implante de Prótese de Valva Cardíaca , Administração Intravenosa , Administração Oral , Hemocultura , Procedimentos Cirúrgicos Cardíacos , Preparações de Ação Retardada , Ecocardiografia , Humanos , Equipe de Assistência ao Paciente , Tomografia por Emissão de Pósitrons , Recidiva , Medição de Risco , Abuso de Substâncias por Via Intravenosa/terapiaRESUMO
BACKGROUND: Coronary catheterization with angiography is often performed prior to surgical valve replacement in infectious endocarditis. There are no existing data as to whether this intervention is clinically necessary or leads to a change in surgical management. In order to determine the frequency with which coronary angiography impacts surgical management in infectious endocarditis, we conducted a retrospective review of surgically managed endocarditis cases at a tertiary care medical center. METHODS: Utilizing the institutional Society of Thoracic Surgeon's database, we identified 598 patients with surgically managed endocarditis between April 29, 2011 and December 31, 2018. Patient variables were recorded, including risk factors for coronary artery disease, whether the patient received coronary angiography prior to surgery, and if the patient underwent coronary artery bypass grafting as part of their valve surgery. RESULTS: There were 430 patients who received coronary catheterization with angiography prior to surgical valve replacement for infectious endocarditis, and 168 patients proceeded to surgery without coronary angiography. Nine percent of patients underwent coronary artery bypass grafting at the time of valve replacement as a result of coronary angiography findings. There was no significant difference in 30-day mortality for patients with endocarditis who underwent coronary angiography when compared with those who did not receive coronary angiography (2.6 vs 2.4%; P = 0.89). CONCLUSIONS: Left heart catheterization with coronary angiography prior to surgical valve replacement leads to coronary artery bypass grafting in the minority of infective endocarditis patients.
Assuntos
Cateterismo Cardíaco , Angiografia Coronária , Endocardite Bacteriana/cirurgia , Adulto , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Endocardite Bacteriana/cirurgia , Sistema de Registros , Abuso de Substâncias por Via Intravenosa/complicações , Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/etiologia , Saúde Global , Humanos , Morbidade/tendências , Taxa de Sobrevida/tendênciasRESUMO
Although transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with aortic stenosis (AS) who are candidates for valve replacement, some patients remain untreated, and their outcomes are not clear. We evaluated 172 consecutive patients with severe symptomatic AS referred for TAVR who declined (n = 55) or were not candidates for (n = 117) intervention. We examined clinical and echocardiographic variables associated with mortality. There were 77 deaths, and mean follow-up was 17.9 ± 10.9 months for survivors. Mortality rate at 1 and 2 years was 39.2% and 52.6%, respectively. There was a significant difference in mortality rate between patients who declined the procedure and those who were not candidates (p = 0.001), with 1-year mortality rates of 20.6% and 48.4%, respectively. On multivariate analysis, 4 variables were independently associated with all-cause mortality: New York Heart Association Class IV heart failure (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.6 to 4.2, p <0.001), glomerular filtration rate <48 ml/min (HR 2.1, 95% CI 1.3 to 3.4, p = 0.002), albumin <3.9 g/dl (HR 1.9, 95% CI 1.2 to 3.1, p = 0.007), and ejection fraction <50% (HR 1.9, 95% CI 1.4 to 3.0, p = 0.01). In this new era with expanded treatment options, patients with severe symptomatic AS who remain untreated after referral for TAVR experience a mortality rate of 39% at 1 year. The presence of advanced heart failure, renal dysfunction, low albumin, and/or left ventricular dysfunction identifies patients at higher risk of mortality.