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1
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White HD, O'Brien SM, Boden WE, Fremes SE, Bangalore S, Reynolds HR, Stone GW, Ali ZA, Parakh N, Lopez-Sendon JL, Wang Y, Chen YQ, Mark DB, Chaitman BR, Spertus JA, Maron DJ, Hochman JS, ISCHEMIA Research Group.. Use of coronary artery bypass graft surgery and percutaneous coronary intervention and associated outcomes in the ISCHEMIA trial. Am Heart J 2025; 289:78-94. [PMID: 40404111 DOI: 10.1016/j.ahj.2025.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2025] [Accepted: 05/15/2025] [Indexed: 05/24/2025]
Abstract
BACKGROUND In the ISCHEMIA Trial, 5,179 patients with stable coronary disease were randomized to initial invasive or conservative management. METHODS PCI was recommended with a SYNTAX score 0 to 22 (low) and CABG with a SYNTAX score ≥33 (high). Either could be recommended for intermediate scores. The composite primary outcome was cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. There were 2 cohorts in this analysis. The descriptive cohort included patients who underwent CABG or PCI within 180 days of randomization and had no primary outcome before revascularization. The comparative cohort excluded patients with prior CABG, single vessel disease, SYNTAX score ≥ 45, and without core laboratory assessment. We focused on the intermediate (23-32) SYNTAX comparative group for which either CABG or PCI could be recommended. RESULTS For 1,935 patients in the descriptive cohort (485 CABG, 1,450 PCI), the SYNTAX score was 27.3 ± 11.0 in the CABG group and 15.3 ± 8.6 in the PCI group, P < .0001. Most patients with low SYNTAX scores underwent PCI (87.1%), while most with high SYNTAX scores underwent CABG (72.6%). For the 1,203 patients (385 CABG, 818 PCI) in the comparative cohort, the adjusted 4-year primary event rate was 14.5% for CABG and 13.2% for PCI (difference 1.3%, 95% CI, -4.9% to 7.7%). For the 346 patients (163 CABG, 183 PCI) in the intermediate SYNTAX group, the adjusted 4-year primary event rate was 10.6% for CABG and 18.3% for PCI (difference -7.6%, 95% CI, -16.1% to 0.9%). CONCLUSIONS Selection of revascularization method resulted in more PCI in the low SYNTAX group and more CABG in the high SYNTAX group. There was no statistical evidence of a difference between PCI and CABG in the intermediate SYNTAX group but the CIs are broad, reflecting uncertainty. CLINICAL TRIALS GOV IDENTIFIER NCT01471522; https://clinicaltrials.gov/ct2/show/NCT01471522.
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Affiliation(s)
- Harvey D White
- Health New Zealand - Te Whatu Ora, Te Toka Tumai, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - William E Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario Canada
| | - Sripal Bangalore
- Department of Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Harmony R Reynolds
- Department of Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Gregg W Stone
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ziad A Ali
- Cardiololgy Department, Cardiovascular Research Foundation, New York, NY, USA; Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA; Cardiology Department, St Francis Hospital, Roslyn, NY, USA
| | - Neeraj Parakh
- Cardiology Department, All India Institute of Medical Sciences, New Delhi, India
| | - Jose Luis Lopez-Sendon
- Cardiology Department, IdiPaz Research Institute and Hospital Universitario La Paz, Madria, Spain
| | - Yixin Wang
- Department of Medicine, Stanford Prevention Research Center, Stanford, CA, USA
| | - Ying Qing Chen
- Department of Medicine, Stanford Prevention Research Center, Stanford, CA, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Duke University, Durham, NC, USA
| | - Bernard R Chaitman
- School of Medicine Center for Comprehensive Cardiovascular Care, Saint Louis University, St. Louis, MO, USA
| | - John A Spertus
- Luke's Mid America Heart Institute, University of Missouri - Kansas City's Healthcare Institute for Innovations in Quality and Saint, Kansas City, MO, USA
| | - David J Maron
- Department of Medicine, Stanford Prevention Research Center, Stanford, CA, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Judith S Hochman
- Department of Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
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Kaczorowski DJ, Takeda K, Atluri P, Cevasco M, Cogswell R, D'Allesandro D, Daneshmand MA, Jeevanandam V, Kapur NK, Milano C, Ono M, Potapov E, Ramzy D, Silvestry SC, Soltesz E, Uriel N. 2025 American Association for Thoracic Surgery (AATS) Expert Consensus Document: Surgical management of acute myocardial infarction and associated complications. J Thorac Cardiovasc Surg 2025:S0022-5223(25)00302-2. [PMID: 40320004 DOI: 10.1016/j.jtcvs.2025.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2025] [Revised: 04/08/2025] [Accepted: 04/08/2025] [Indexed: 05/07/2025]
Abstract
BACKGROUND Complications of acute myocardial infarction (AMI) can result in significant morbidity and mortality. This document reports the findings and recommendations of a multidisciplinary group of experts on the management of patients with complications of AMI, with particular focus on the use of mechanical circulatory support in this context. METHODS Through the American Association of Thoracic Surgery Clinical Practice Standards Committee, a committee of multidisciplinary experts, including both cardiologists and cardiothoracic surgeons, was established. A list of topics was developed. Committee members were divided into subgroups that developed relevant questions. A systematic literature review was then performed, and the results were synthesized into clinical recommendations. Expert consensus was then established using the Delphi process. RESULTS Based on the results of the systematic literature review, as well as the clinical expertise of the committee, clinical recommendations were developed. Each of these recommendations, the strength of each recommendation, and the level or quality of evidence on which the recommendation was based are presented here. Topics addressed include general considerations, revascularization strategies, cardiogenic shock, papillary muscle rupture, postinfarction ventricular septal defect, free wall rupture, arrhythmias, and the use of durable therapies in this context. CONCLUSIONS AMI may result in cardiogenic shock, malignant arrhythmias, or mechanical complications, each of which is associated with high mortality. Prompt management of these complications, including consideration for mechanical circulatory support, is warranted.
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Affiliation(s)
- David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Pavan Atluri
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Rebecca Cogswell
- Cardiovascular Division, University of Minnesota, Minneapolis, Minn
| | | | | | | | - Navin K Kapur
- Division of Cardiology, Tufts Medicine, Boston, Mass
| | | | - Minoru Ono
- Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Evgenij Potapov
- Department of Thoracic and Cardiovascular Surgery, Deutsches Herzzentrum der Charite, Berlin, Germany
| | - Danny Ramzy
- Department of Cardiothoracic and Vascular Surgery, UT Health Houston McGovern School of Medicine, Houston, Tex
| | - Scott C Silvestry
- Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Edward Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nir Uriel
- New York Presbyterian-Columbia University Irving Medical Center, New York, NY
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Musialek P, Bonati LH, Bulbulia R, Halliday A, Bock B, Capoccia L, Eckstein HH, Grunwald IQ, Lip PL, Monteiro A, Paraskevas KI, Podlasek A, Rantner B, Rosenfield K, Siddiqui AH, Sillesen H, Van Herzeele I, Guzik TJ, Mazzolai L, Aboyans V, Lip GYH. Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases. Cardiovasc Res 2025; 121:13-43. [PMID: 37632337 DOI: 10.1093/cvr/cvad135] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023] Open
Abstract
Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.
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Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, St. John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | | | - Richard Bulbulia
- Medical Research Council Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | | | - Laura Capoccia
- Department of Surgery 'Paride Stefanini', Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, University of Dundee, Dundee, UK
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
| | | | - Andre Monteiro
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
- Division of Radiological and Imaging Sciences, University of Nottingham, Nottingham, UK
| | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Campus Grosshadern, Munich, Germany
| | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Henrik Sillesen
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Tomasz J Guzik
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Lucia Mazzolai
- Department of Angiology, University Hospital Lausanne, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, CHRU Dupuytren Limoges, Limoges, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Ma H, Lin S, Li X, Wang Y, Yang W, Dou K, Liu S, Zheng Z. The modified heart team protocol facilitated the revascularization decision-making quality in complex coronary artery disease. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2025; 40:ivaf023. [PMID: 39932002 PMCID: PMC11845249 DOI: 10.1093/icvts/ivaf023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Accepted: 02/07/2025] [Indexed: 02/23/2025]
Abstract
OBJECTIVES A lack of standardization in heart team implementation potentially leads to suboptimal decision-making quality, and we previously established a modified heart team protocol to improve the decision-making quality. The present trial was to validate the effect of the modified heart team implementation protocol on improving the decision-making quality versus the conventional protocol in complex coronary artery disease (CAD). METHODS Eligible interventional cardiologists, cardiac surgeons and non-interventional cardiologists were randomly allocated to the intervention or control arm and established 12 heart teams in each arm. The 12 heart teams in each arm were randomly divided into 6 pairs, and 480 historic cases with complex CAD into 6 sets of 80 cases. In each arm, each set of 80 cases was discussed independently by one pair of heart teams, with each case finally receiving two heart team decisions ('pairwise decisions'). The intervention arm conducted heart team decision-making according to the previously established protocol and the control arm based on guideline recommendations. The primary outcome was the overall percent agreement of the inter-team pairwise decisions. Decision-making appropriateness was further analysed. RESULTS A total of 36 cardiac surgeons, 36 interventional cardiologists and 12 non-interventional cardiologists from 26 centres were enrolled. The overall percent agreement was significantly higher in the intervention arm than the control arm (72.1% vs 65.8%, P = 0.04; kappa 0.51 vs 0.37). Both team-level (19.4% vs 33.0%; P < 0.001) and specialist-level (interventional cardiologists, 19.8% vs 37.7%, P < 0.001; cardiac surgeons, 19.8% vs 28.7%, P < 0.001) inappropriateness rate of decision-making was significantly lower in the intervention arm than the control arm. CONCLUSIONS The modified heart team implementation protocol improved the decision-making quality and appropriateness compared with the guideline-based protocol.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shen Lin
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Central China Subcenter of the National Center for Cardiovascular Diseases, Zhengzhou, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weixian Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kefei Dou
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central China Cardiovascular Hospital, Central China Subcenter of National Center for Cardiovascular Diseases, Zhengzhou, China
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Lavanchy I, Passos L, Aymard T, Grünenfelder J, Emmert MY, Corti R, Gaemperli O, Biaggi P, Reser D. Gender-Tailored Heart Team Decision Making Equalizes Outcomes for Female Patients after Aortic Valve Replacement through Right Anterior Small Thoracotomy (RAST). J Cardiovasc Dev Dis 2024; 11:329. [PMID: 39452299 PMCID: PMC11508425 DOI: 10.3390/jcdd11100329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 09/25/2024] [Accepted: 10/09/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort. METHODS This study is a retrospective analysis of 338 patients (2013-2022). Subgroup analysis included a gender-dependent comparison of age groups ≤60 and >60 years. RESULTS Women were older (69.27 ± 7.98 vs. 64.15 ± 11.47, p < 0.001) with higher Euroscore II (1.25 ± 0.73 vs. 0.94 ± 0.45, p < 0.001). Bypass and cross-clamp time were shorter (109.36 ± 30.8 vs. 117.65 ± 33.1 minutes, p = 0.01; 68.26 ± 21.5 vs. 74.36 ± 23.3 minutes, p = 0.01), while ICU, hospital stay and atrial fibrillation were higher (2.48 ± 8.2 vs. 1.35 ± 1.4 days, p = 0.005; 11 ± 7.8 vs. 9.48 ± 2.3 days, p = 0.002; 6.7% vs. 4.4%, p = 0.024). Mortality was 0.9%, while stroke was 0.6%. Age subgroup analysis showed that women were older (p = 0.025) with longer ICU and hospital stays (p < 0.001, p = 0.007). On mid-term follow-up (4.52 ± 2.67 years) of 315 patients (94.3%), there was no significant difference in survival, MACCE and re-intervention comparing gender and age groups. CONCLUSIONS Despite older age, higher Euroscore II, longer ICU and hospital stay in women, mortality, MACCE and reoperation were low and comparable in gender and age groups. We believe that our patient-tailored heart team decision making combined with RAST translates into gender-tailored medicine, which equalizes the widely reported negative outcomes of female patients after cardiac surgery.
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Affiliation(s)
- Isabel Lavanchy
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Laina Passos
- Department of Cardiac and Vascular Surgery, University Hospital Bern, Freiburgstrasse 20, 3010 Bern, Switzerland;
| | - Thierry Aymard
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Jürg Grünenfelder
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Maximilian Y. Emmert
- Deutsches Herzzentrum der Charite (DHZC), Department of Cardiothoracic and Vascular Surgery, 13353 Berlin, Germany;
- Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Roberto Corti
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Oliver Gaemperli
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Patric Biaggi
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
| | - Diana Reser
- Department of Cardiac Surgery and Cardiology, Heart Clinic, Hirslanden Hospital, Witellikerstrasse 40, 8032 Zurich, Switzerland; (T.A.); (J.G.); (R.C.); (O.G.); (P.B.)
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Wilson T, James MT, Southern D, Har B, Graham MM, Brass N, Bainey K, Fedak PWM, Sajobi TT, Wilton SB. Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study. J Am Heart Assoc 2024; 13:e035356. [PMID: 39248266 PMCID: PMC11935616 DOI: 10.1161/jaha.123.035356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/22/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. METHODS AND RESULTS From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. CONCLUSIONS Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.
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Affiliation(s)
- Todd Wilson
- Department of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
| | - Matthew T. James
- Department of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
| | - Danielle Southern
- Centre for Health Informatics, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Bryan Har
- Department of Cardiac SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
| | - Michelle M. Graham
- Mazankowski Alberta Heart Institute, University of AlbertaEdmontonCanada
| | - Neil Brass
- CKHui Heart CentreUniversity of AlbertaAlbertaCanada
| | - Kevin Bainey
- Mazankowski Alberta Heart Institute, University of AlbertaEdmontonCanada
| | - Paul W. M. Fedak
- Department of Cardiac SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
| | - Tolulope T. Sajobi
- Department of Community Health SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
| | - Stephen B. Wilton
- Department of Community Health SciencesUniversity of CalgaryAlbertaCanada
- Department of Cardiac SciencesUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, University of CalgaryAlbertaCanada
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Hamiko M, Konrad N, Lagemann D, Gestrich C, Masseli F, Oezkur M, Velten M, Treede H, Duerr GD. Follow-Up and Outcome after Coronary Bypass Surgery Preceded by Coronary Stent Implantation. Thorac Cardiovasc Surg 2024; 72:423-434. [PMID: 37286186 PMCID: PMC11379534 DOI: 10.1055/a-2107-0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Guidelines on myocardial revascularization define recommendations for percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Only little information exists on long-term follow-up and quality of life (QoL) after CABG preceded by PCI. The aim of our study was to evaluate the impact of prior PCI on outcome and QoL in patients with stable coronary artery disease who underwent CABG. METHODS In our retrospective study, CABG patients were divided in: CABG preceded by PCI: PCI-first (PCF), and CABG-only (CO) groups. The PCF group was further divided in guideline-conform (GCO) and guideline nonconform (GNC) subgroups, according to the SYNTAX score (2014 European Society of Cardiology [ESC]/European Association for Cardio-Thoracic Surgery [EACTS] guidelines). Thirty days mortality, major adverse cardiac events, and QoL using the European Quality-of-Life-5 Dimensions were evaluated. RESULTS A total of 997 patients were analyzed, of which 784 underwent CABG without (CO), and 213 individuals with prior PCI (PCF). The latter group consisted of 67 patients being treated in accordance (GCO), and 24 in discordance (GNC) to the 2014 ESC/EACTS guidelines. Reinfarction (PCF: 3.8% vs. CO: 1.0%; p = 0.024), re-angiography (PCF: 17.6% vs. CO: 9.0%; p = 0.004), and re-PCI (PCF: 10.4% vs. CO: 3.0%; p < 0.001) were observed more frequently in PCF patients. Also, patients reported better health status in the CO compared to PCF group (CO: 72.48 ± 19.31 vs. PCF: 68.20 ± 17.86; p = 0.01). Patients from the guideline nonconform subgroup reported poorer health status compared to the guideline-conform group (GNC: 64.23 ± 14.56 vs. GCO: 73.42 ± 17.66; p = 0.041) and were more likely to require re-PCI (GNC: 18.8% vs. GCO: 2.4%; p = 0.03). Also, GNC patients were more likely to have left main stenosis (GCO: 19.7% vs. GNC: 37.5%; p < 0.001) and showed higher preinterventional SYNTAX score (GCO: 18.63 ± 9.81 vs. GNC: 26.67 ± 5.07; p < 0.001). CONCLUSION PCI preceding CABG is associated with poorer outcomes such as reinfarction, re-angiography, and re-PCI, but also worse health status and higher rehospitalization. Nevertheless, results were better when PCI was guideline-conformant. This data should impact the Heart Team decision.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Nicole Konrad
- Department of Cardiac Surgery, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Doreen Lagemann
- Department of Cardiac Surgery, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Christopher Gestrich
- Department of Cardiac Surgery, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Franz Masseli
- Department of Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Rheinland-Pfalz, Germany
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8
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Koshy AN, Stone GW, Sartori S, Dhulipala V, Giustino G, Spirito A, Farhan S, Smith KF, Feng Y, Vinayak M, Salehi N, Tanner R, Hooda A, Krishnamoorthy P, Sweeny JM, Khera S, Dangas G, Filsoufi F, Mehran R, Kini AS, Fuster V, Sharma SK. Outcomes Following Percutaneous Coronary Intervention in Patients With Multivessel Disease Who Were Recommended for But Declined Coronary Artery Bypass Graft Surgery. J Am Heart Assoc 2024; 13:e033931. [PMID: 38818962 PMCID: PMC11255644 DOI: 10.1161/jaha.123.033931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/01/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. METHODS AND RESULTS Consecutive patients with stable ischemic heart disease and unprotected left main or 3-vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI-recommended; (2) CABG-eligible but refused CABG (CABG-refusal); and (3) CABG-ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI-recommended, n=1718 [46.6%]), CABG-refusal (n=1595 [43.3%]), and CABG-ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG-ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI-recommended, CABG-refusal, and CABG-ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG-refusal (hazard ratio [HR], 1.67 [95% CI, 1.08-3.56]; P=0.02) and CABG-ineligible patients (HR, 3.26 [95% CI, 1.28-3.65]; P=0.004) groups compared with the reference PCI-recommended group, driven by increased death and stroke. CONCLUSIONS Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real-world data to inform shared decision-making discussions.
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Affiliation(s)
- Anoop N. Koshy
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
- Department of CardiologyThe Royal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Cardiology and The University of MelbourneAustin HealthMelbourneVictoriaAustralia
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Vishal Dhulipala
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Kenneth F. Smith
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Yihan Feng
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Manish Vinayak
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Negar Salehi
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Richard Tanner
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Amit Hooda
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Parasuram Krishnamoorthy
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Joseph M. Sweeny
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Sahil Khera
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Farzan Filsoufi
- Department of Cardiac SurgeryIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Annapoorna S. Kini
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Samin K. Sharma
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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9
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Serruys PW, Revaiah PC. Leveraging QFR and SYNTAX score II 2020 to guide PCI versus CABG decisions in multivessel CAD - broadening QFR's utility. EUROINTERVENTION 2024; 20:EIJ-E-24-00024. [PMID: 39230481 PMCID: PMC11067512 DOI: 10.4244/eij-e-24-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Affiliation(s)
- Patrick W Serruys
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
| | - Pruthvi C Revaiah
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, University of Galway, Galway, Ireland
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10
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Riojas RA, Lawton JS, Metkus TS. The heart team: the multidisciplinary approach to coronary artery disease. VESSEL PLUS 2024; 8:6. [PMID: 39524214 PMCID: PMC11545650 DOI: 10.20517/2574-1209.2023.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
The recommendation to employ a heart team to guide revascularization has persisted for over a decade. Despite evidence for improved adherence to guidelines, widespread adoption of the heart team approach has been limited. This review delves into the history of the guidelines endorsing the use of a heart team and the supporting data. Additionally, it outlines some attributes of a successful heart team, and how the heart team has been run at several large academic centers. Finally, it reviews some of the barriers to a heart team and future considerations.
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Affiliation(s)
- Ramon A. Riojas
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Malcolm Grow Medical Clinics and Surgery Center, Joint Base-Andrews, MD 20762, USA
| | - Jennifer S. Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Thomas S. Metkus
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Divison of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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11
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Su X, Ma H, Lin S, Dou K, Zheng Z. Safety and feasibility of a real-time electronic heart team decision-making approach in patients with complex coronary artery disease: a protocol for a randomised controlled trial (EHEART trial). BMJ Open 2023; 13:e076864. [PMID: 37989362 PMCID: PMC10668163 DOI: 10.1136/bmjopen-2023-076864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION The implementation of a heart team still faces many challenges which may be facilitated with advanced communication technology. There is a knowledge gap to support the use of an electronic real-time heart team decision-making approach based on communication technology in the real clinical practice and evaluate its safety and feasibility in patients with complex coronary artery disease (CAD). METHODS AND ANALYSIS The EHEART (Electronic HEArt team with Real-Time decision-making) trial is a prospective, multicentre, two-arm, randomised controlled trial that will randomise 490 patients with complex CAD to either an electronic real-time heart team group or conventional heart team group. For patients allocated to the real-time electronic group, heart team meetings will be initiated during the coronary angiography and guided by a supporting system based on communication technology to help with information synchronisation, real-time communication between specialists, meeting process recording and assistance and joint decision-making with patients' families. The primary and safety endpoint is a composite of all-cause death, myocardial infarction, stroke, revascularisation or re-angina hospital admission at 1 year. The primary secondary outcome is the time interval from the coronary angiography to the final treatment, which is the major indicator of feasibility. We will also compare the practical feasibility from the specialist's and patient's perspectives (for example, specialist's workload and patient's decision results) between the two groups. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (no. 2022-1749). Informed consent will be obtained from all participants. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05514210).
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Affiliation(s)
- Xiaoting Su
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kefei Dou
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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12
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Lee C, Tully A, Fang JC, Sugeng L, Elmariah S, Grubb KJ, Young MN. Building and Optimizing the Interdisciplinary Heart Team. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101067. [PMID: 39129880 PMCID: PMC11308725 DOI: 10.1016/j.jscai.2023.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 08/13/2024]
Abstract
A multidisciplinary care team model, or Heart Team approach, has become a central tenet of cardiovascular care. Though initially applied to the management of heart transplantation and subsequently complex coronary artery disease, the Heart Team is now utilized broadly across cardiovascular medicine, including in the treatment of valvular disease, pulmonary embolism, cardiogenic shock, high-risk pregnancies in patients with pre-existing cardiovascular disease, and adult congenital heart disease. The Heart Team model improves interdisciplinary collaboration among specialties, adherence to societal guidelines, and shared decision-making with patients and families. In this review, we highlight the development and rationale supporting the Heart Team model, address the challenges of implementing a multidisciplinary care team, and discuss the optimal methods to continue to build, optimize, and implement this approach.
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Affiliation(s)
- Christopher Lee
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew Tully
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - James C. Fang
- Division of Cardiology, University of Utah Health, Salt Lake City, Utah
| | - Lissa Sugeng
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Sammy Elmariah
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Kendra J. Grubb
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Michael N. Young
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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13
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Protty MB, Valenzuela T, Sharaf A, Shome J, Hasan S, Chase A, UlHaq Z, Ionescu A, Khurana A, Jenkins G, Obaid DR, Choudhury A, Hailan A. Predictors of 1- and 12-month mortality in bifurcation coronary intervention: a contemporary perspective. Future Cardiol 2023; 19:353-361. [PMID: 37449460 DOI: 10.2217/fca-2023-0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Aim: Bifurcation-PCI is performed frequently, although without extensive evidence to back up a definitive solution for its complexity. We set out to identify factors associated with 1- and 12-month mortality after bifurcation-PCI between 2017 and 2021 in our tertiary center in Wales, UK. Results: Of 732 bifurcation PCI cases (mean age 69; 25% female), 67% were in ACS, 42% were left main PCI and 25.3% involved two-stent strategy. 30-day and 12-month mortality were 1.9 and 8.2%, respectively. Age, diabetes, smoking and renal failure are associated with mortality after bifurcation-PCI, while the choice between provisional and 2-stent strategies did not impact mortality/TLR. Conclusion: Awareness of 'real-world' outcomes of bifurcation-PCI should be used for appropriate patient selection, technique planning and procedural consent.
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Affiliation(s)
- Majd B Protty
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Systems Immunity University Research Institute, Cardiff University, Cardiff, CF14 4XN, UK
| | - Tom Valenzuela
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Ahmed Sharaf
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Joy Shome
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Saad Hasan
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Alexander Chase
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Zia UlHaq
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Adrian Ionescu
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Ayush Khurana
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Geraint Jenkins
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
| | - Daniel R Obaid
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Anirban Choudhury
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
- Swansea University Medical School, Swansea, SA1 8EN, UK
| | - Ahmed Hailan
- Department of Cardiology, Morriston Cardiac Centre, Swansea, SA6 6NL, UK
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14
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Pereira FJSS, Menezes MP, Naranjo GCS, Delamain JHH, Costa JR, Issa M, Amato VL, Feres F, Farsky PS. Change of Strategy in Coronary Artery Bypass Graft Surgery Waiting List during the COVID-19 Pandemic: One-Year Follow-Up. Arq Bras Cardiol 2023; 120:e20220582. [PMID: 37098990 PMCID: PMC10263414 DOI: 10.36660/abc.20220582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 12/03/2022] [Accepted: 01/11/2023] [Indexed: 04/27/2023] Open
Affiliation(s)
| | - Marília Prudente Menezes
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | | | - José Ribamar Costa
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Mario Issa
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Vivian Lerner Amato
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Fausto Feres
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Pedro Silvio Farsky
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
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15
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Huseynov A, Reinhardt J, Chandra L, Dürschmied D, Langer HF. Novel Aspects Targeting Platelets in Atherosclerotic Cardiovascular Disease—A Translational Perspective. Int J Mol Sci 2023; 24:ijms24076280. [PMID: 37047253 PMCID: PMC10093962 DOI: 10.3390/ijms24076280] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
Platelets are important cellular targets in cardiovascular disease. Based on insights from basic science, translational approaches and clinical studies, a distinguished anti-platelet drug treatment regimen for cardiovascular patients could be established. Furthermore, platelets are increasingly considered as cells mediating effects “beyond thrombosis”, including vascular inflammation, tissue remodeling and healing of vascular and tissue lesions. This review has its focus on the functions and interactions of platelets with potential translational and clinical relevance. The role of platelets for the development of atherosclerosis and therapeutic modalities for primary and secondary prevention of atherosclerotic disease are addressed. Furthermore, novel therapeutic options for inhibiting platelet function and the use of platelets in regenerative medicine are considered.
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16
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Lee G, Chikwe J, Milojevic M, Wijeysundera HC, Biondi-Zoccai G, Flather M, Gaudino MFL, Fremes SE, Tam DY. ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis. Eur Heart J 2023; 44:796-812. [PMID: 36632841 DOI: 10.1093/eurheartj/ehac803] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.
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Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, 1 King's College Circle, Toronto, ON M5S1A8, Canada
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd a3600, Los Angeles, CA 90048, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, M4N 3M5, University of Toronto, Toronto, ON, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Roma RM, Italy
- Mediterranea Cardiocentro, Via Orazio, 2, 80122 Napoli, NA, Italy
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 1300 York Ave, NY New York, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
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17
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Porterie J, Kalavrouziotis D, Dumont E, Paradis JM, De Larochellière R, Rodés-Cabau J, Mohammadi S. Clinical impact of the heart team on the outcomes of surgical aortic valve replacement among octogenarians. J Thorac Cardiovasc Surg 2023; 165:1010-1019.e5. [PMID: 33840473 DOI: 10.1016/j.jtcvs.2021.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/17/2021] [Accepted: 03/02/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The effectiveness of a multidisciplinary heart team in the management of patients with severe symptomatic aortic stenosis is unknown. This study evaluated the impact of a heart team on the outcomes of surgical aortic valve replacement in octogenarians. METHODS Between May 2007 and January 2016, 528 patients aged 80 years or more were referred to our institutional heart team for a transcatheter aortic valve replacement. Among these, 101 were redirected to surgical aortic valve replacement (heart team group). These patients were compared with a surgical aortic valve replacement cohort (n = 506) without prior heart team screening (non-heart team group), taken from the same time period. Propensity score matching with bootstrap analysis was performed; 76 heart team patients were matched to 76 non-heart team patients. Early and late outcomes including survival and readmission for cardiovascular causes were compared. RESULTS Matched subgroups were largely comparable; congestive heart failure and echocardiographic pulmonary hypertension were more prevalent in the heart team group. In-hospital mortality was significantly lower in the matched heart team group (0% vs 6.0%, bootstrap mean difference 6.0%, 95% confidence interval, 2.2-9.8). The risk of stroke, low cardiac output state, reexploration for bleeding, pneumonia, and prolonged ventilation was also significantly lower in the heart team group. There was no significant between-group difference regarding late survival (hazard ratio, 0.86, 95% confidence interval, 0.55-1.33, P = .49) or readmission for cardiovascular reasons (hazard ratio, 0.70, 95% confidence interval, 0.41-1.20, P = .19). CONCLUSIONS Preoperative multidisciplinary assessment of octogenarians by a heart team was associated with lower in-hospital mortality and adverse events after surgical aortic valve replacement.
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Affiliation(s)
- Jean Porterie
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Robert De Larochellière
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Ma H, Lin S, Li X, Wang Y, Xu B, Zheng Z. Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases. BMJ Open 2022; 12:e064761. [PMID: 36456006 PMCID: PMC9716884 DOI: 10.1136/bmjopen-2022-064761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/14/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD). METHODS AND ANALYSIS Eighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry. TRIAL REGISTRATION NUMBER NCT05039567.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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Avtaar Singh SS, Nappi F. Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study. Biomedicines 2022; 10:3010. [PMID: 36551766 PMCID: PMC9775403 DOI: 10.3390/biomedicines10123010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies. METHODS A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework. RESULTS The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon. CONCLUSION The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.
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Affiliation(s)
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord of Saint-Denis, 93200 Saint-Denis, France
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20
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Sobolev B, Kuramoto L. Time of coronary revascularization: methodology of a mediation analysis study. CMAJ Open 2022; 10:E1052-E1058. [PMID: 36735232 PMCID: PMC9828946 DOI: 10.9778/cmajo.20210183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The advantage of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI), established in trials, may not be generalizable to populations in which the method of treatment determines the time to treatment. We sought to describe the methodology of a population-based observational study for assessing how changes in time to treatment may affect the comparative effectiveness of these 2 methods of coronary revascularization. METHODS We propose a framework of causal mediation analysis to compare the outcomes of choosing CABG over PCI, if patients selected for either method waited the same amount of time had they undergone a PCI. We will include patients who underwent a first-time, nonurgent isolated CABG or single-session PCI for multivessel or left main coronary artery disease from January 2001 to December 2016, in British Columbia. We will use absolute risk difference as a measure of the total effect of choosing CABG over PCI and partition it into the direct effect of the treatment choice and the effect mediated by the treatment-specific timing. INTERPRETATION Understanding how time to treatment mediates the relation between method of revascularization and outcomes will have implications for treatment selection, resource allocation and planning benchmarks. Findings on the benefits and risks of performing PCI or CABG within a certain time will guide multidisciplinary teams in determining the appropriate revascularization method for individual patients.
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Affiliation(s)
- Boris Sobolev
- School of Population and Public Health (Sobolev), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Lisa Kuramoto
- School of Population and Public Health (Sobolev), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC
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21
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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22
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Bani Hani A, Salhiyyah K, Salameh M, Abu Abeeleh M, Al Smady M, Al Rawashdeh M, Abu Fares H, Al-Ammouri I. Atrial Septal Defect Repair in Adolescent and Adult Patients, a Cross Sectional Study at Jordan University Hospital, a Tertiary Hospital in a Developing Country. Int J Gen Med 2022; 15:3517-3524. [PMID: 35392029 PMCID: PMC8979831 DOI: 10.2147/ijgm.s356502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/08/2022] [Indexed: 11/27/2022] Open
Abstract
Objective We aim to report our heart team's experience in repair of Secundum atrial septal defect (ASD) in adolescent and adult patients at Jordan University Hospital (JUH). Methodology A retrospective observational study of 44 patients who underwent secundum ASD closure by transcatheter closure (TCC) or Minimally Invasive Cardiac Surgery (MICS) at JUH. Patients who were treated at an age of 14 years or older regardless of the age of diagnosis were included. SPSS and Microsoft Excel were used to analyze the data. Results A total of 44 patients with secundum ASD were treated during the period of (January 2015 and December 2019). The mean age was 34.1 (±14.3) years. Thirty-four patients underwent TCC, 9 underwent surgical closure and one had a hybrid procedure. We had no mortality and 2 minor morbidities. After a mean follow-up period of 13.2-/+13.6 months, most patients experienced improved symptoms, and there was a significant reduction of right ventricular dimension from 33.1 (±8.74) to 24 (±4.67) mm (p=0.0001). Conclusion ASD closure whether TCC or MICS is a safe procedure with very low morbidity. A heart team approach is a necessity in the era of advances in both MICS surgery and TCC approach. A heart team provides the patients with a variety of safe and cosmetic solutions that allow the patients to have a fast management and recovery phase in rapid time through providing the merits and avoiding the complications of each modality, the team allows low volume centers in developing countries to achieve an excellent outcome.
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Affiliation(s)
- Amjad Bani Hani
- Department of General Surgery, Division of Cardiac Surgery, The University of Jordan, Amman, Jordan
| | - Kareem Salhiyyah
- Department of Cardiac Science, Middle East University, Amman, Jordan
| | - Mohammad Salameh
- Department of General Surgery, Division of Cardiac Surgery, The University of Jordan, Amman, Jordan
| | - Mahmoud Abu Abeeleh
- Department of General Surgery, Division of Cardiac Surgery, The University of Jordan, Amman, Jordan
| | - Moaath Al Smady
- Department of General Surgery, Division of Cardiac Surgery, The University of Jordan, Amman, Jordan
| | - Mohammad Al Rawashdeh
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Jordan, Amman, Jordan
| | - Hala Abu Fares
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Jordan, Amman, Jordan
| | - Iyad Al-Ammouri
- Department of Pediatrics, Division of Pediatric Cardiology, The University of Jordan, Amman, Jordan
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23
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Tomaniak M, Masdjedi K, Neleman T, Kucuk IT, Vermaire A, van Zandvoort LJC, Van Boven N, van Dalen BM, Soei LK, den Dekker WK, Kardys I, Wilschut JM, Diletti R, Zijlstra F, Van Mieghem NM, Daemen J. Three-dimensional QCA-based vessel fractional flow reserve (vFFR) in Heart Team decision-making: a multicentre, retrospective, cohort study. BMJ Open 2022; 12:e054202. [PMID: 35379622 PMCID: PMC8981358 DOI: 10.1136/bmjopen-2021-054202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/25/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of three-vessel three-dimensional (3D) quantitative coronary angiography (QCA)-based fractional flow reserve (FFR) computation in patients discussed within the Heart Team in whom the treatment decision was based on angiography alone, and to evaluate the concordance between 3D QCA-based vessel FFR (vFFR)-confirmed functional lesion significance and revascularisation strategy as proposed by the Heart Team. DESIGN Retrospective, cohort. SETTING 3D QCA-based FFR indices have not yet been evaluated in the context of Heart Team decision-making; consecutive patients from six institutions were screened for eligibility and three-vessel vFFR was computed by blinded analysts. PARTICIPANTS Consecutive patients with chronic coronary syndrome or unstable angina referred for Heart Team consultation. Exclusion criteria involved: presentation with acute myocardial infarction (MI), significant valve disease, left ventricle ejection fraction <30%, inadequate quality of angiogram precluding vFFR computation in all three epicardial coronary arteries (ie, absence of a minimum of two angiographic projections with views of at least 30° apart, substantial foreshortening/overlap of the vessel, poor contrast medium injection, ostial lesions, chronic total occlusions). PRIMARY AND SECONDARY OUTCOME MEASURES Discordance between vFFR-confirmed lesion significance and revascularisation was assessed as the primary outcome measure. Rates of major adverse cardiac events (MACE) defined as cardiac death, MI and clinically driven revascularisation were reported. RESULTS Of a total of 1003 patients were screened for eligibility, 416 patients (age 65.6±10.6, 71.2% male, 53% stable angina) were included. The most important reason for screening failure was insufficient quality of the angiogram (43%). Discordance between vFFR confirmed lesion significance and revascularisation was found in 124/416 patients (29.8%) corresponding to 149 vessels (46/149 vessels (30.9%) were reclassified as significant and 103/149 vessels (69.1%) as non-significant by vFFR). Over a median of 962 days, the cumulative incidence of MACE was 29.7% versus 18.5% in discordant versus concordant patients (p=0.031). CONCLUSIONS vFFR computation is feasible in around 40% of the patients referred for Heart Team discussion, a limitation that is mostly based on insufficient quality of the angiogram. Three vessel vFFR screening indicated discordance between vFFR confirmed lesion significance and revascularisation in 29.8% of the patients.
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Affiliation(s)
- Mariusz Tomaniak
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Kaneshka Masdjedi
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Tara Neleman
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Ibrahim T Kucuk
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Alise Vermaire
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Laurens J C van Zandvoort
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Nick Van Boven
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Bas M van Dalen
- Sint Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands
| | - Loe Kie Soei
- Sint Franciscus Gasthuis & Vlietland Hospital, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Thorax Center, Rotterdam, the Netherlands
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24
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives. JACC. ASIA 2022; 2:119-138. [PMID: 36339118 PMCID: PMC9627854 DOI: 10.1016/j.jacasi.2021.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.
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Key Words
- BMS, bare-metal stent(s)
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent(s)
- DK, double-kissing
- FFR, fractional flow reserve
- IVUS, intravascular ultrasound
- LAD, left anterior descending artery
- LCX, left circumflex artery
- LMCA, left main coronary artery
- LVEF, left ventricular ejection fraction
- MACCE, major adverse cardiac or cerebrovascular events
- MI, myocardial infarction
- MLA, minimal lumen area
- PCI, percutaneous coronary intervention
- RCT, randomized clinical trial
- coronary artery bypass grafting
- iFR, instantaneous wave-free ratio
- left main coronary artery disease
- percutaneous coronary intervention
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Jonik S, Marchel M, Pędzich-Placha E, Pietrasik A, Rdzanek A, Huczek Z, Kochman J, Budnik M, Piątkowski R, Scisło P, Czub P, Wilimski R, Maksym J, Grabowski M, Opolski G, Mazurek T. Optimal Management of Patients with Severe Coronary Artery Disease following Multidisciplinary Heart Team Approach-Insights from Tertiary Cardiovascular Care Center. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:3933. [PMID: 35409613 PMCID: PMC8997622 DOI: 10.3390/ijerph19073933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023]
Abstract
Background: The purpose of this retrospective study was to investigate outcomes of patients with severe coronary artery disease (CAD) after implementing various treatment strategies following multidisciplinary Heart Team (MHT) discussion. Methods Primary and secondary endpoints and quality of life during a mean (SD) follow-up of 37 (14) months of patients with severe CAD (three-vessel [3-VD] or/and left main [LM] disease) qualified after MHT discussion to optimal medical treatment (OMT) alone, OMT and coronary artery bypass grafting (CABG), or OMT and percutaneous coronary intervention (PCI) were evaluated. As the primary endpoint, major adverse cardiac or cerebrovascular events (MACCE) (i.e., death from any cause, stroke, myocardial infarction, or repeat/need for revascularization) were considered. Result: From 2016 to 2019, 176 MHT meetings were held, and a total of 1286 participants with severe CAD and completely implemented MHT decisions (OMT, CABG, or PCI for 251, 356, and 679 patients, respectively) were included. The occurrence of the primary endpoint was significantly increased in OMT-group (154 (61.4%) vs. CABG and PCI groups—110 (30.9%) and 302 (44.5%) patients, respectively (p < 0.05). For interventional strategies only—CABG was associated with reduced rates of MACCE and repeat revascularization, while the superiority of PCI for stroke and disabling stroke was observed (p < 0.05). The general health status assessed at the end of the follow-up was significantly better for patients who underwent CABG or PCI than in the OMT group (p < 0.05). Conclusions: In this real-life study, we presented a single-center experience of providing optimal medical care for patients with severe CAD following MHT discussion.
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Affiliation(s)
- Szymon Jonik
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Michał Marchel
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Ewa Pędzich-Placha
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Arkadiusz Pietrasik
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Adam Rdzanek
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Zenon Huczek
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Janusz Kochman
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Monika Budnik
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Radosław Piątkowski
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Piotr Scisło
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Paweł Czub
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.)
| | - Radosław Wilimski
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.)
| | - Jakub Maksym
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Marcin Grabowski
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Grzegorz Opolski
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
| | - Tomasz Mazurek
- Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (M.M.); (E.P.-P.); (A.P.); (A.R.); (Z.H.); (J.K.); (M.B.); (R.P.); (P.S.); (J.M.); (M.G.); (G.O.)
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Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Non-Protected Left Main Coronary Artery Disease: 1-Year Outcomes in a High Volume Single Center Study. Life (Basel) 2022; 12:life12030347. [PMID: 35330098 PMCID: PMC8953531 DOI: 10.3390/life12030347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: There is clear evidence of a significant reduction in all major cardiovascular adverse events (MACE) by coronary artery bypass grafting (CABG) in left main coronary artery stenosis (LMCS), but revascularization by percutaneous coronary artery intervention (PCI) shows an increasingly important role as an alternative to CABG. Several recent trials aiming to test the difference in mortality between the two types of revascularization found conflicting data. The aim of this study is to determine whether PCI is non-inferior to CABG with respect to the occurrence of MACE at 1 year in patients with significant LMCS. Material and methods: We prospectively enrolled 296 patients with chronic or acute coronary syndromes and significant LM stenosis. The angiography that recommended the revascularization procedure was used for the calculation of the Syntax II score, in order to classify the patients as low-, intermediate- or high-risk. Low- and high-risk patients were revascularized with either PCI or CABG, according to current guidelines, and were included in the subgroup S1. The second subgroup (S0) included intermediate-risk patients (Syntax II score 23–32), in whom the type of revascularization was chosen depending on the decision of the heart team or the patient preference. Patients were monitored according to the chosen mode of revascularization—PCI or CABG. LM revascularization was performed in all the patients. Clinical endpoints included cardiac death, myocardial infarction, need for revascularization and stroke. Patients were evaluated at 1 year after revascularization. Event rates were estimated using the Kaplan–Meier analysis in time to the first event. Results: At 1-year follow-up, a primary endpoint occurred in 35/95 patients in the CABG group and 37/201 in the PCI group. There were no significant differences between the 2 treatment strategies in the 1-year components of the end-point. However, a tendency to higher occurrence of cardiac death (HR = 1.48 CI (0.55–3.9), p = 0.43), necessity of repeat revascularization (HR = 1.7, CI (0.81–3.6), p = 0.16) and stroke (HR = 1.52, CI (1.15–2.93), p = 0.58) were present after CABG. Contrariwise, although without statistical significance, MI was more frequent after PCI (HR = 2, CI (0.78–5.2), p = 0.14). The Kaplan–Meier estimates in subgroups demonstrated the same tendency to higher rates for cardiac death, repeat revascularization and stroke after CABG, and higher rates of MI after PCI. Although without statistical significance, patients with an intermediate-risk showed a slightly lower risk of MACE after PCI than CABG. With the exception of dyslipidemia and gender, other cardiovascular risk factors were in favor of CABG (CKD, obesity). Conclusion: In patients with LMCS, PCI with drug-eluting stents was non-inferior to CABG with respect to the composite of cardiac death, myocardial infarction, repeat revascularization and stroke at 1 year, even in patients with intermediate Syntax II risk score.
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Nenna A, Nappi F, Spadaccio C, Greco SM, Pilato M, Stilo F, Montelione N, Catanese V, Lusini M, Spinelli F, Chello M. Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review. Future Cardiol 2022; 18:219-234. [PMID: 35006006 DOI: 10.2217/fca-2020-0244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.
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Affiliation(s)
- Antonio Nenna
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Francesco Nappi
- Cardiac surgery, Centre Cardiologique du Nord, Rue des Moulins Gémeaux 32, Saint Denis 93200, Paris, France
| | - Cristiano Spadaccio
- Cardiac surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank G814DY, Glasgow, United Kingdom
| | - Salvatore Matteo Greco
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy.,Cardiac surgery, ISMETT-IRCCS, Via Ernesto Tricomi 5, Palermo 90127, Italy
| | - Michele Pilato
- Cardiac surgery, ISMETT-IRCCS, Via Ernesto Tricomi 5, Palermo 90127, Italy
| | - Francesco Stilo
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Nunzio Montelione
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Vincenzo Catanese
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Mario Lusini
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Francesco Spinelli
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
| | - Massimo Chello
- Cardiovascular surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 200, Rome 00128, Italy
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Kalal N, Deora S, Singh K. Nurses in cardiac catheterization laboratory: An important pillar of “heart team”. HEART AND MIND 2022. [DOI: 10.4103/hm.hm_75_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sabatine MS, Bergmark BA, Murphy SA, O'Gara PT, Smith PK, Serruys PW, Kappetein AP, Park SJ, Park DW, Christiansen EH, Holm NR, Nielsen PH, Stone GW, Sabik JF, Braunwald E. Percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in left main coronary artery disease: an individual patient data meta-analysis. Lancet 2021; 398:2247-2257. [PMID: 34793745 DOI: 10.1016/s0140-6736(21)02334-5] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal revascularisation strategy for patients with left main coronary artery disease is uncertain. We therefore aimed to evaluate long-term outcomes for patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). METHODS In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane database using the search terms "left main", "percutaneous coronary intervention" or "stent", and "coronary artery bypass graft*" to identify randomised controlled trials (RCTs) published in English between database inception and Aug 31, 2021, comparing PCI with drug-eluting stents with CABG in patients with left main coronary artery disease that had at least 5 years of patient follow-up for all-cause mortality. Two authors (MSS and BAB) identified studies meeting the criteria. The primary endpoint was 5-year all-cause mortality. Secondary endpoints were cardiovascular death, spontaneous myocardial infarction, procedural myocardial infarction, stroke, and repeat revascularisation. We used a one-stage approach; event rates were calculated by use of the Kaplan-Meier method and treatment group comparisons were made by use of a Cox frailty model, with trial as a random effect. In Bayesian analyses, the probabilities of absolute risk differences in the primary endpoint between PCI and CABG being more than 0·0%, and at least 1·0%, 2·5%, or 5·0%, were calculated. FINDINGS Our literature search yielded 1599 results, of which four RCTs-SYNTAX, PRECOMBAT, NOBLE, and EXCEL-meeting our inclusion criteria were included in our meta-analysis. 4394 patients, with a median SYNTAX score of 25·0 (IQR 18·0-31·0), were randomly assigned to PCI (n=2197) or CABG (n=2197). The Kaplan-Meier estimate of 5-year all-cause death was 11·2% (95% CI 9·9-12·6) with PCI and 10·2% (9·0-11·6) with CABG (hazard ratio 1·10, 95% CI 0·91-1·32; p=0·33), resulting in a non-statistically significant absolute risk difference of 0·9% (95% CI -0·9 to 2·8). In Bayesian analyses, there was an 85·7% probability that death at 5 years was greater with PCI than with CABG; this difference was more likely than not less than 1·0% (<0·2% per year). The numerical difference in mortality was comprised more of non-cardiovascular than cardiovascular death. Spontaneous myocardial infarction (6·2%, 95% CI 5·2-7·3 vs 2·6%, 2·0-3·4; hazard ratio [HR] 2·35, 95% CI 1·71-3·23; p<0·0001) and repeat revascularisation (18·3%, 16·7-20·0 vs 10·7%, 9·4-12·1; HR 1·78, 1·51-2·10; p<0·0001) were more common with PCI than with CABG. Differences in procedural myocardial infarction between strategies depended on the definition used. Overall, there was no difference in the risk of stroke between PCI (2·7%, 2·0-3·5) and CABG (3·1%, 2·4-3·9; HR 0·84, 0·59-1·21; p=0·36), but the risk was lower with PCI in the first year after randomisation (HR 0·37, 0·19-0·69). INTERPRETATION Among patients with left main coronary artery disease and, largely, low or intermediate coronary anatomical complexity, there was no statistically significant difference in 5-year all-cause death between PCI and CABG, although a Bayesian approach suggested a difference probably exists (more likely than not <0·2% per year) favouring CABG. There were trade-offs in terms of the risk of myocardial infarction, stroke, and revascularisation. A heart team approach to communicate expected outcome differences might be useful to assist patients in reaching a treatment decision. FUNDING No external funding.
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Affiliation(s)
- Marc S Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter K Smith
- Department of Surgery (Cardiothoracic), Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC, USA
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, UK
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands; Medtronic, Maastricht, Netherlands
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | | | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Per H Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Numata S, Kumamaru H, Miyata H, Yaku H, Motomura N. Comparison of long-term outcomes between off-pump and on-pump coronary artery bypass grafting using Japanese nationwide cardiovascular surgery database. Gen Thorac Cardiovasc Surg 2021; 70:531-540. [PMID: 34800223 DOI: 10.1007/s11748-021-01731-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 11/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In Japan, off-pump coronary artery bypass (OPCAB) is more common than on-pump coronary artery bypass. Superior early results of OPCAB have been reported; however, long-term results were still unclear. Purpose of this study is to evaluate the clinical outcomes of OPCAB in Japan using Japan Adult Cardiovascular Surgery Database. METHODS Between 2008 and 2010, 23,633 patients who underwent isolated coronary artery bypass were reported in database. We selected the cases from the hospital with mean annual coronary surgery volume of more than 50. Among the total of 7724 cases at 41 institutions, 2150 (31.2%) on-pump coronary artery bypass (ONCAB) and 5574 (68.8%) OPCAB cases were included. Propensity score (PS) matching was performed using PS developed from patient characteristics and preoperative factors resulting in 2007 cases matched pairs. Long-term follow-up data on patients' mortality and stroke were collected. RESULTS In-hospital mortality was significantly lower in OPCAB (ONCAB 1.1%, OPCAB 0.4% p = 0.01). Stroke was low in OPCAB group (ONCAB 1.7%, OPCAB 0.8%, p = 0.01). There was no statistically significant difference between OPCAB and ONCAB regarding 7-year overall survival (86.1% vs 88.1% respectively), composite outcomes (72.0% vs 73.9% respectively), or cardiac deaths (97.3% vs 97.1% respectively). Subgroup analysis (more than 75 years old) showed a worse trend in OPCAB group. Only in OPCAB group, incomplete revascularization significantly influenced 7-year survival. CONCLUSIONS OPCAB is associated with early prognostic benefits; however, it might be less favorable outcomes in the long term when patients are older or with incomplete revascularization.
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Affiliation(s)
- Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465-Kajiicho Kamigyo, Kyoto, 602-8566, Japan.
| | - Hikaru Kumamaru
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
- Department of Healthcare Quality Assessment Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465-Kajiicho Kamigyo, Kyoto, 602-8566, Japan
| | - Noboru Motomura
- Japan Cardiovascular Surgery Database Organization, Tokyo, Japan
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31
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Jonik S, Marchel M, Pędzich-Placha E, Huczek Z, Kochman J, Ścisło P, Czub P, Wilimski R, Hendzel P, Opolski G, Grabowski M, Mazurek T. Heart Team for Optimal Management of Patients with Severe Aortic Stenosis-Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center. J Clin Med 2021; 10:5408. [PMID: 34830690 PMCID: PMC8623928 DOI: 10.3390/jcm10225408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. METHODS Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. RESULTS From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). CONCLUSIONS We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.
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Affiliation(s)
- Szymon Jonik
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Michał Marchel
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Ewa Pędzich-Placha
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Janusz Kochman
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Piotr Ścisło
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Paweł Czub
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Radosław Wilimski
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Piotr Hendzel
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Tomasz Mazurek
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
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Ma H, Lin S, Li X, Dou K, Yang W, Feng W, Liu S, Wu Y, Peng B, Zheng Z. Exploring optimal heart team protocol to improve decision-making stability for complex coronary artery disease: a sequential explanatory mixed method study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:739-749. [PMID: 34634101 DOI: 10.1093/ehjqcco/qcab074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022]
Abstract
AIMS Current guidelines recommend a heart team in the decision making for patients with complex coronary artery disease (CAD). However, the decision-making stability of these teams has not been evaluated and the optimum protocol is unknown. We assessed inter-team agreement for revascularization decision-making and influencing factors to inform the development of a heart team protocol. METHODS AND RESULTS This sequential, explanatory mixed methods study included (1) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (2) a qualitative study that used semi-structured interviews with heart team members to identify factors influencing decision-making discrepancy. We randomly selected 101 complex CAD patients. Sixteen specialists were randomly assigned to 4 heart teams to make decisions for these patients. The primary outcome kappa of inter-team decision-making agreement was moderate (kappa 0.58). Factors influencing decision-making were generated through inductive thematic analysis and were summarized by 3 themes (specialist quality, team composition, meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at 5 levels: specialist selection, specialist training, team composition, team training, and meeting process. A detailed protocol on the integration of guidelines, previous experience and recommendations was generated to establish and deploy a qualified heart team. CONCLUSIONS Agreement between heart teams for revascularization decision-making in complex CAD patients was moderate. Potential factors associated with decision discrepancies were summarized and recommendations were generated. A detailed heart team protocol was designed and should be validated in future.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kefei Dou
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Weixian Yang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Feng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Wu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Boshizhang Peng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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Metkus TS, Lindsley J, Fair L, Riley S, Berry S, Sahetya S, Hsu S, Gilotra NA. Quality of Heart Failure Care in the Intensive Care Unit. J Card Fail 2021; 27:1111-1125. [PMID: 34625130 PMCID: PMC8514052 DOI: 10.1016/j.cardfail.2021.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 01/02/2023]
Abstract
Patients with heart failure (HF) who are seen in an intensive care unit (ICU) manifest the highest-risk, most complex and most resource-intensive disease states. These patients account for a large relative proportion of days spent in an ICU. The paradigms by which critical care is provided to patients with HF are being reconsidered, including consideration of various multidisciplinary ICU staffing models and the development of acute-response teams. Traditional HF quality initiatives have centered on the peri- and postdischarge period in attempts to improve adherence to guideline-directed therapies and reduce readmissions. There is a compelling rationale for expanding high-quality efforts in treating patients with HF who are receiving critical care so we can improve outcomes, reduce preventable harm, improve teamwork and resource use, and achieve high health-system performance. Our goal is to answer the following question: For a patient with HF in the ICU, what is required for the provision of high-quality care? Herein, we first review the epidemiology of HF syndromes in the ICU and identify relevant critical care and quality stakeholders in HF. We next discuss the tenets of high-quality care for patients with HF in the ICU that will optimize critical care outcomes, such as ICU staffing models and evidence-based management of cardiac and noncardiac disease. We discuss strategies to mitigate preventable harm, improve ICU culture and conduct outcomes review, and we conclude with our summative vision of high-quality of ICU care for patients with HF; our vision includes clinical excellence, teamwork and ICU culture.
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Affiliation(s)
- Thomas S Metkus
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Linda Fair
- Johns Hopkins Hospital, Baltimore, Maryland
| | - Sarah Riley
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Berry
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarina Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Hsu
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A Gilotra
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Comparison of Outcomes of Patients with vs without Previous Coronary Artery Bypass Graft Surgery Presenting with ST-Segment Elevation Acute Myocardial Infarction. Am J Cardiol 2021; 154:33-40. [PMID: 34243937 DOI: 10.1016/j.amjcard.2021.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 11/24/2022]
Abstract
The outcomes of patients with previous coronary bypass graft surgery (CABG) presenting with ST-segment elevation acute myocardial infarction (STEMI) have received limited study. We compared the clinical and procedural characteristics and outcomes of STEMI patients with and without previous CABG in a contemporary multicenter STEMI registry between 2003 and 2020. The primary outcomes of the study were mortality and major cardiac adverse events (MACE: death, MI or stroke). Survival curves were derived using the Kaplan-Meier method and compared with the log-rank test. Of the 13,893 patients included in the analyses, 7.2% had previous CABG. Mean age was 62.4 ± 13.6 years, most patients (71%) were men and 22% had diabetes. Previous CABG patients were older (69.0 ± 11.7 vs 61.9 ± 13.6 years, p <0.001) and more likely to have diabetes (40% vs 21%, p <0.001) compared with patients without previous CABG. Previous CABG patients had higher mortality and MACE at 5 years (p <0.001). Outcomes were similar with saphenous vein graft vs native coronary culprits. Previous CABG remained associated with mortality from discharge to 18 months (p = 0.044) and from 18 months to 5 years (p <0.001) after adjusting for baseline characteristics. Long term outcomes after STEMI were worse among patients with previous CABG compared with patients without previous CABG, even after adjustment for baseline characteristics.
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Lee J, Ahn JM, Kim JH, Jeong YJ, Hyun J, Yang Y, Lee JS, Park H, Kang DY, Lee PH, Park DW, Park SJ. Prognostic Effect of the SYNTAX Score on 10-Year Outcomes After Left Main Coronary Artery Revascularization in a Randomized Population: Insights From the Extended PRECOMBAT Trial. J Am Heart Assoc 2021; 10:e020359. [PMID: 34227392 PMCID: PMC8483455 DOI: 10.1161/jaha.120.020359] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background The long‐term prognostic effect of the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) for left main coronary artery disease is controversial. Methods and Results In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus‐Eluting Stent in Patients With Left Main Coronary Artery Disease) trial, 600 patients with left main coronary artery disease were randomized to undergo PCI with drug‐eluting stents (n=300) or CABG (n=300). We compared 10‐year outcomes after PCI and CABG according to SS categories and evaluated the predictive value of SS in each revascularization arm. The primary outcome was a major adverse cardiac or cerebrovascular event (composite of death, myocardial infarction, stroke, or ischemia‐driven target‐vessel revascularization) at 10 years. Among 566 patients with valid SS measurement at baseline, 240 (42.4%) had low SS, 200 (35.3%) had intermediate SS, and 126 (22.3%) had high SS. The 10‐year rates of major adverse cardiac or cerebrovascular events were not significantly different between PCI and CABG in low (21.6% versus 22.2%, P=0.97), intermediate (31.8% versus 22.2%; P=0.13), and high SS (46.2% versus 35.7%; P=0.31) (P‐for‐interaction=0.46). There were no significant interactions between SS categories and revascularization modalities for death (P=0.92); composite of death, myocardial infarction, or stroke (P=0.87); and target‐vessel revascularization (P=0.06). Higher SS categories were associated with higher risks for major adverse cardiac or cerebrovascular events in the PCI arm but not in the CABG arm. Conclusions Ten‐year clinical outcomes between PCI and CABG were not significantly different according to the SS. The SS was predictive of major adverse cardiac or cerebrovascular events after PCI but not after CABG. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03871127.
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Affiliation(s)
- Junghoon Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Jung-Min Ahn
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Ju Hyeon Kim
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Yeong Jin Jeong
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Junho Hyun
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Yujin Yang
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Ji Sung Lee
- Division of Clinical Epidemiology and Biostatistics Center for Medical Research and Information Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Hanbit Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Do-Yoon Kang
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Pil Hyung Lee
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Duk-Woo Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
| | - Seung-Jung Park
- Department of Cardiology Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Korea
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Abstract
Combined surgical and percutaneous coronary revascularization, ie, hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as a 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding, and same-day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score.
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Seelandt JC, Walker K, Kolbe M. "A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing. Adv Simul (Lond) 2021; 6:7. [PMID: 33663598 PMCID: PMC7931165 DOI: 10.1186/s41077-021-00161-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly. METHODS We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding. RESULTS In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units. CONCLUSION The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.
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Affiliation(s)
- Julia Carolin Seelandt
- Simulation Center, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Katie Walker
- New York City, Health + Hospitals Simulation Center, 1400 Pelham Parkway South, Building 4, 2nd Floor, Bronx, NY 10461 USA
| | - Michaela Kolbe
- Simulation Center, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
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Omar AS, Hanoura S, Shouman Y, Sivadasan PC, Sudarsanan S, Osman H, Pattath AR, Singh R, AlKhulaifi A. Intensive care outcome of left main stem disease surgery: A single center three years’ experience. World J Crit Care Med 2021; 10:12-21. [PMID: 33505869 PMCID: PMC7805253 DOI: 10.5492/wjccm.v10.i1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/09/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.
AIM To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.
METHODS Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups.
RESULTS Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures.
CONCLUSION Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients’ care.
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Affiliation(s)
- Amr S Omar
- Department of Cardiothoracic Surgery/Cardiac Anaesthesia and Intensive Care Unit, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Medicine, Weill Cornell Medical College in Qatar, Doha 3050, DA, Qatar
- Department of Critical Care Medicine, Beni Suef University, Beni Suef 62511, Egypt
| | - Samy Hanoura
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Anesthesia, Alazhar University, Cairo 11651, Egypt
| | - Yasser Shouman
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Praveen C Sivadasan
- Department of Cardiothoracic Surgery/Intensive Care Unit Section, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Suraj Sudarsanan
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Hany Osman
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Anesthesia, Alazhar University, Cairo 11651, Egypt
| | - Abdul Rasheed Pattath
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Rajvir Singh
- Department of Medical Research, Hamad Medical Corporation, Doha 3050, DA, Qatar
| | - Abdulaziz AlKhulaifi
- Department of Cardiothoracic Surgery, Hamad Medical Corporation, Doha 3050, DA, Qatar
- Department of Cardiothoracic Surgery, Qatar University, Doha 3050, DA, Qatar
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Percutaneous Versus Surgical Revascularization for Acute Myocardial Infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 31:50-54. [PMID: 33339773 DOI: 10.1016/j.carrev.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) is a common medical condition in our clinical practice that should be treated with appropriate revascularization in a timely manner. Percutaneous revascularization (PR) has been the first-line treatment option when feasible. Limited data is available comparing PR to surgical revascularization (SR) in the AMI setting. METHODS Study population was extracted from the 2016 Nationwide Readmissions Data using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for AMI, PR, SR, and procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay (LOS), stroke, acute kidney injury, bleeding, need for blood transfusion, acute respiratory failure, and total hospital charges. RESULTS The study identified 45,539 discharges with a principal admission diagnosis of AMI (38.7% ST elevation and 61.3% non-ST elevation) who had either PR or SR as a principal procedure (79.1% PR versus 20.9% SR). Single vessel revascularization was performed in 67.8% (93.1% had PR versus 6.9% had SR, p < 0.01). Multivessel revascularization was performed in 32.2% (64.8% had PR versus 35.2% had SR, p < 0.01). 83% of SR was in the setting of non-ST elevation AMI (NSTEMI). In comparison to SR, PR was associated with higher in-hospital all-cause mortality (3.7% versus 2.2%, p < 0.01), shorter LOS (4.3 versus 11.6 days, p < 0.01), and lower incidence of post-procedural stroke (1.0% versus 1.8%, p < 0.01), acute kidney injury (14.9% versus 24.8%, p < 0.01), bleeding (4.3% versus 47.1%, p < 0.01), need for blood transfusion (2.9% versus 18.5%, p < 0.01), acute respiratory failure (10.7% versus 19.8%, p < 0.01), and total hospital charges (120,590$ versus 229,917$, p < 0.01). These results persist after adjustment for baseline characteristics. In a subgroup analysis, SR mortality benefit persisted in patients who had multivessel revascularization (in both ST and non-ST elevation AMI), but not in single vessel revascularization. CONCLUSIONS In patients presented with AMI, PR was associated with higher in-hospital all-cause mortality but lower morbidity, shorter LOS, and lower total hospital charges than SR. However, the mortality benefit of SR was seen in multivessel revascularization only, and not in single vessel revascularization.
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Dourado LOC, Pereira AC, Poppi NT, Cavalcante R, Gaiotto F, Dallan LAO, Bittencourt MS, Cesar LAM, Gowdak LHW. The Role of the Heart Team in Patients with Diffuse Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2020; 69:584-591. [PMID: 33225435 DOI: 10.1055/s-0040-1718936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis. METHODS Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based on individual scores, the Heart Team's and the specialists' scores were calculated and compared. RESULTS The examiners evaluated 154 coronary territories, of which 85 (55.2%) were protected. The Heart Team's accuracy for predicting the angiographic success of the surgery was 74.9%, almost equal to that of the surgeons alone (73.2%). Only the interventional cardiologist predicted left anterior descending territory grafting success. The Heart Team had good specificity and reasonable sensitivity, and the surgeons had high sensitivity and low specificity in predicting angiographic success. CONCLUSION The multispecialty Heart Team achieved good accuracy in predicting the angiographic coronary artery bypass graft success in patients with diffuse CAD, with a high specificity and reasonable sensitivity.
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Affiliation(s)
| | - Alexandre C Pereira
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Nilson Tavares Poppi
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Rafael Cavalcante
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | - Fabio Gaiotto
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
| | | | - Marcio Sommer Bittencourt
- Division of Internal Medicine, Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, Sao Paulo, Brazil
| | - Luiz Antonio M Cesar
- Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
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Takahashi K, Serruys PW, Fuster V, Farkouh ME, Spertus JA, Cohen DJ, Park SJ, Park DW, Ahn JM, Kappetein AP, Head SJ, Thuijs DJ, Onuma Y, Kent DM, Steyerberg EW, van Klaveren D. Redevelopment and validation of the SYNTAX score II to individualise decision making between percutaneous and surgical revascularisation in patients with complex coronary artery disease: secondary analysis of the multicentre randomised controlled SYNTAXES trial with external cohort validation. Lancet 2020; 396:1399-1412. [PMID: 33038944 DOI: 10.1016/s0140-6736(20)32114-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Randomised controlled trials are considered the gold standard for testing the efficacy of novel therapeutic interventions, and typically report the average treatment effect as a summary result. As the result of treatment can vary between patients, basing treatment decisions for individual patients on the overall average treatment effect could be suboptimal. We aimed to develop an individualised decision making tool to select an optimal revascularisation strategy in patients with complex coronary artery disease. METHODS The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries between March, 2005, and April, 2007. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to either the percutaneous coronary intervention (PCI) group or coronary artery bypass grafting (CABG) group. The SYNTAXES study ascertained 10-year all-cause deaths. We used Cox regression to develop a clinical prognostic index for predicting death over a 10-year period, which was combined, in a second stage, with assigned treatment (PCI or CABG) and two prespecified effect-modifiers, which were selected on the basis of previous evidence: disease type (three-vessel disease or left main coronary artery disease) and anatomical SYNTAX score. We used similar techniques to develop a model to predict the 5-year risk of major adverse cardiovascular events (defined as a composite of all-cause death, non-fatal stroke, or non-fatal myocardial infarction) in patients receiving PCI or CABG. We then assessed the ability of these models to predict the risk of death or a major adverse cardiovascular event, and their differences (ie, the estimated benefit of CABG versus PCI by calculating the absolute risk difference between the two strategies) by cross-validation with the SYNTAX trial (n=1800 participants) and external validation in the pooled population (n=3380 participants) of the FREEDOM, BEST, and PRECOMBAT trials. The concordance (C)-index was used to measure discriminative ability, and calibration plots were used to assess the degree of agreement between predictions and observations. FINDINGS At cross-validation, the newly developed SYNTAX score II, termed SYNTAX score II 2020, showed a helpful discriminative ability in both treatment groups for predicting 10-year all-cause deaths (C-index=0·73 [95% CI 0·69-0·76] for PCI and 0·73 [0·69-0·76] for CABG) and 5-year major adverse cardiovascular events (C-index=0·65 [0·61-0·69] for PCI and C-index=0·71 [0·67-0·75] for CABG). At external validation, the SYNTAX score II 2020 showed helpful discrimination (C-index=0·67 [0·63-0·70] for PCI and C-index=0·62 [0·58-0·66] for CABG) and good calibration for predicting 5-year major adverse cardiovascular events. The estimated treatment benefit of CABG over PCI varied substantially among patients in the trial population, and the benefit predictions were well calibrated. INTERPRETATION The SYNTAX score II 2020 for predicting 10-year deaths and 5-year major adverse cardiovascular events can help to identify individuals who will benefit from either CABG or PCI, thereby supporting heart teams, patients, and their families to select optimal revascularisation strategies. FUNDING The German Heart Research Foundation and the Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Amsterdam Universities Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland.
| | - Valentin Fuster
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Centro Nacional De Investigaciones Cardiovasculares Carlos III, Madrid, Spain
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and The Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, ON, Canada
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA
| | - David J Cohen
- University of Missouri-Kansas City, Kansas City, MO, USA
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Daniel Jfm Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden, Netherlands; University Medical Centre, Leiden, Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands
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Affiliation(s)
- Julian Yeoh
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Nuis RJ, Jadoon A, van Dalen BM, Dulfer K, Snelder SM, Yazdi MT, Masdjedi K, den Dekker WK, Diletti R, Wilschut J, Daemen J, Lenzen MJ, Zijlstra F, Smits PC, Van Mieghem NM. Patient perspectives on left main stem revascularization strategies, the OPINION-2 study. J Cardiol 2020; 77:271-278. [PMID: 33041162 DOI: 10.1016/j.jjcc.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Treatment preferences in patients with left main (LM) stem disease and no prior revascularization are unknown. The objectives of this study were to determine (i) patient-reported importance ratings of particular features related to percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, (ii) how these features determine treatment preference, and (iii) how educational and psychosocial background influence this preference. METHODS In this prospective, multicenter study a total of 500 patients without previous revascularization who underwent diagnostic angiography for suspected coronary disease were asked to complete a case-vignette on a (hypothetical) LM stenosis qualifying for both PCI and CABG, in addition to 6 validated questionnaires to assess the influence of psychosocial factors on treatment preference. RESULTS Overall, 90% favored PCI over CABG because of the lower bleeding and stroke risk despite a higher likelihood for repeat revascularization. By multivariable regression, the only independent determinant of treatment preference for CABG was lower educational level (14% in low vs. 8% in higher educated patients, OR: 3.22, CI: 1.16-8.95, p=0.025) while psychosocial variables were not associated. Compared to higher educated patients, those with lower educational level suffered more from depression, anxiety, loneliness, and uncertainty. CONCLUSIONS Overall, patients who are informed about risk and benefits of each treatment modality clearly favor PCI over CABG and particularly value lower short-term morbidity while being aware of higher risk of repeat revascularization. Lower educational level was associated with a higher prevalence of psychosomatic phenotypes and a 14% preference for CABG. Educational and psychosocial background matter in the revascularization strategy decision-making process.
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Affiliation(s)
- Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Adeel Jadoon
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bas M van Dalen
- Department of Cardiology, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - Karolijn Dulfer
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sanne M Snelder
- Department of Cardiology, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - Mehrdad Talebian Yazdi
- Department of Cardiology, Franciscus Gasthuis & Vlietland Hospital, Rotterdam, The Netherlands
| | - Kaneshka Masdjedi
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mattie J Lenzen
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Wierda E, van Veghel D, Hirsch A, de Mol BAJM. Heart teams in the Netherlands: From teamwork to data‑driven decision-making. Neth Heart J 2020; 28:73-77. [PMID: 32780335 PMCID: PMC7419410 DOI: 10.1007/s12471-020-01452-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
For all patients with cardiovascular disease requiring an intervention, this is a major life event. The heart team concept is one of the most exciting and effective team modalities to ensure cost-effective application of invasive cardiovascular care. It optimises patient selection in a complex decision-making process and identifies risk/benefit ratios of different interventions. Informed consent and patient safety should be at the centre of these decisions. To deal with increased load of medical data in the future, artificial intelligence could enable objective and effective interpretation of medical imaging and decision support. This technical support is indispensable to meet current patient and societal demands for informed consent, shared decision-making, outcome improvement and safety. The heart team should be restructured with clear leadership, accountability, and process and outcome measurement of interventions. In this way, the heart team concept in the Netherlands will be ready for the future.
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Affiliation(s)
- E Wierda
- Department of Cardiology, Dijklander Hospital, location Hoorn, Hoorn, The Netherlands.
| | - D van Veghel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A Hirsch
- Department of Cardiology and Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - B A J M de Mol
- Department of Cardiothoracic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kezerle L, Yohanan E, Cohen A, Merkin M, Ishay Y, Weinstein JM, Cafri C. The impact of Heart Team discussion on decision making for coronary revascularization in patients with complex coronary artery disease. J Card Surg 2020; 35:2719-2724. [PMID: 32743834 DOI: 10.1111/jocs.14892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. METHODS We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group). RESULTS There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P < .01). HT discussion led to a significant delay to PCI (8 ± 5 vs 1.8 ± 4 days; P = .02), while surgical revascularization times were not affected. CONCLUSION HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.
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Affiliation(s)
- Louise Kezerle
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eli Yohanan
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Avshalom Cohen
- Southern Division, Clalit Health Services, Tel Aviv, Israel
| | - Miri Merkin
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yaron Ishay
- Deparment of Cardiothoracic Surgery, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jean M Weinstein
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Carlos Cafri
- Department of Cardiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Tsang MB, Schwalm JD, Gandhi S, Sibbald MG, Gafni A, Mercuri M, Salehian O, Lamy A, Pericak D, Jolly S, Sheth T, Ainsworth C, Velianou J, Valettas N, Mehta S, Pinilla N, Yanagawa B, Zhang L, Chu V, Parry D, Whitlock R, Dyub A, Cybulsky I, Semelhago L, Ioannou K, Hameed A, Wright D, Mulji A, Darvish-Kazem S, Gupta N, Alshatti A, Natarajan MK. Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease. JAMA Netw Open 2020; 3:e2012749. [PMID: 32777060 PMCID: PMC7417969 DOI: 10.1001/jamanetworkopen.2020.12749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. OBJECTIVE To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. MAIN OUTCOMES AND MEASURES The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. RESULTS Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). CONCLUSIONS AND RELEVANCE The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial.
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Affiliation(s)
- Michael B. Tsang
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J. D. Schwalm
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sumeet Gandhi
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Matthew G. Sibbald
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amiram Gafni
- Center for Health Economics and Policy Analysis, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Omid Salehian
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andre Lamy
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dan Pericak
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sanjit Jolly
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tej Sheth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Velianou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Valettas
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shamir Mehta
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Natalia Pinilla
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiovascular Surgery, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Li Zhang
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Victor Chu
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Parry
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Dunedin Hospital, Otago, New Zealand
| | - Richard Whitlock
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Adel Dyub
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Irene Cybulsky
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lloyd Semelhago
- Division of Cardiovascular Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kostas Ioannou
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Adnan Hameed
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Douglas Wright
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amin Mulji
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Saeed Darvish-Kazem
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Brampton Civic Hospital, William Osler Health System, Brampton, Ontario, Canada
| | - Nandini Gupta
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Alshatti
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Van den Eynde J, Bennett J, McCutcheon K, Adriaenssens T, Desmet W, Dubois C, Sinnaeve P, Verbelen T, Jacobs S, Oosterlinck W. Heart team 2.0: A decision tree for minimally invasive and hybrid myocardial revascularization. Trends Cardiovasc Med 2020; 31:382-391. [PMID: 32712328 DOI: 10.1016/j.tcm.2020.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022]
Abstract
Recent years have seen an important shift in the target population for myocardial revascularization. Patients are increasingly presenting with more complex coronary artery disease (CAD), but also with multiple comorbidities and frailty. At the same time, minimally invasive strategies such as Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB) and Percutaneous Coronary Interventions (PCI) have been developed, which might be more appealing for this group of patients. As a result, the landscape of options for myocardial revascularization is evolving while adequate use of all resources is required to ensure optimal patient care. Heart Teams are confronted with the challenge of incorporating the new minimally invasive strategies into the decision process, yet current guidelines do not fully address this challenge. In this review, the current evidence regarding outcomes, indications, benefits, and risks of off-pump coronary artery bypass grafting (OPCAB), MIDCAB, PCI, and hybrid coronary revascularization (HCR) are discussed. Based on this evidence and on experiences from Heart Team discussions, a new decision tree is proposed that incorporates recent advances in minimally invasive revascularization strategies, thereby optimizing adequate delivery of care for each individual patient's needs. Introducing all important considerations in a logical way, this tool facilitates the decision-making process and might ensure appropriate use of resources and optimal care for individual patients.
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Affiliation(s)
- Jef Van den Eynde
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Keir McCutcheon
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Walter Desmet
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steven Jacobs
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Diseases, Research Unit of Cardiac Surgery, University Hospitals Leuven, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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Bianco V, Kilic A, Mulukutla SR, Gleason TG, Kliner D, Aranda-Michel E, Brown JA, Wang Y, Allen CC, Habertheuer A, Sultan I. Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes. Semin Thorac Cardiovasc Surg 2020; 33:368-377. [PMID: 32712423 DOI: 10.1053/j.semtcvs.2020.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 07/02/2020] [Indexed: 01/09/2023]
Abstract
As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh R Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher C Allen
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 4449] [Impact Index Per Article: 889.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Massetti M, Chiariello GA. The extended heart: cardiac surgery serving more hospitals. Eur Heart J Suppl 2020; 22:E91-E95. [PMID: 32523448 PMCID: PMC7270971 DOI: 10.1093/eurheartj/suaa069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The Heart Team is becoming ever more central in delivering cardiovascular care, embodying a modern aspect of medical practice, designed to place the patient at the 'center' of a team with different specialists, all contributing to the definition of the most appropriate therapeutic actions. We prospectively analyzed 200 consecutive patients (2015-2017). Patients were evaluated independently by a cardiologist and a cardiac surgeon, each deciding the most appropriate therapeutic action. At a later time, the same patient, was evaluated by the Heart Team. For the first 100 patients the rate of concurrence between cardiologist and cardiac surgeon as well as among each specialist and the Heart Team, was relatively low (51 and 42% respectively). For the following 100 patients the concurrence rate was significantly higher (75 and 70% respectively). The systematic and collegial discussion of the patients in the contest of the Heart Team, steered toward an evolution of each specialist in the group settings. The Electronic Heart Team (e-Heart Team) employing video conference support, applied to the first 65 patients with promising results, represent a further advancement in the delivery of care, by reducing the distance from the 'Hub' center, and the specialist in the 'Spoke' facility, who from simple source of the patient, now becomes an essential part of the therapeutic decision process. The Heart Team environment can deeply affect patients management and improve treatment results, by sharing the expertise and overcoming the limitations of the individual disciplines, thus reaching the common goal of the patient's best available treatment.
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Affiliation(s)
- Massimo Massetti
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Alfonso Chiariello
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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