CONTEXTE : Pour limiter la propagation de la maladie a coronavirus 2019 (COVID19), de nombreux pays ont decide de reduire le nombre d'interventions chirurgicales non urgentes, ce qui a cree des ...retards en chirurgie partout dans le monde. Notre objectif etait d'evaluer l'ampleur du retard pour ce type d'interventions en Ontario, au Canada, ainsi que le temps et les ressources necessaires pour y remedier. METHODES : Nous avons consulte 6 bases de donnees administratives decrivant la population ontarienne et canadienne pour degager la distribution du volume chirurgical et de la cadence des salles d'operation pour chaque type d'interventions et chaque region, et con naitre la duree d'occupation d'un lit d'hopital et d'un lit de soins intensifs. Les donnees utilisees concernent l'ensemble ou une partie de la periode du 1er janvier 2017 au 13 juin 2020. Nous avons estime l'ampleur du retard accumule et predit le temps necessaire pour le reprendre dans un scenario avec capacite d'appoint de + 10% (ajout d'un jour a 50% de la capacite par semaine) a l'aide de modeles de series chronologiques, de modeles de files d'attente et d'une analyse de sensibilite probabiliste. RESULTATS : Entre le 15 mars et le 13 juin 2020, le retard en chirurgie a l'echelle de l'Ontario s'est accru de 148 364 operations (intervalle de prevision a 95% 124 508-174 589) au total, et en moyenne de 11 413 operations par semaine. Pour reprendre le retard accumule, il faudra environ 84 semaines (intervalle de confiance IC a 95% 46-145) et une cadence hebdomadaire de 717 patients (IC a 95% 326-1367), qui elle demande 719 heures passees au bloc operatoire (IC a 95% 431-1038), 265 lits d'hopital (IC a 95% 87-678) et 9 lits de soins intensifs (IC a 95% 4-20) par semaine. INTERPRETATION : L'ampleur du retard en chirurgie du a la COVID-19 laisse entrevoir de graves consequences pour la phase de reprise en Ontario. Le cadre qui nous a servi a modeliser la reprise du retard peut etre adapte ailleurs, avec des donnees locales, pour faciliter la planification.
The cardiovascular literature is limited by the lack of consensus on what are the best metrics for reporting social determinants of health (SDH) or social deprivation, and if they should be reported ...as a single metric or separately by their domains.
A systematic review of the literature on cardiovascular surgeries and procedures was conducted, identifying articles from January 1, 2010, to December 31, 2023, that studied the relationship between health outcomes after cardiovascular procedures or surgeries and SDH/social deprivation. The cardiovascular procedures/surgeries of interest were coronary and valve surgeries and procedures including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), valve replacement or repair, and transcatheter aortic valve intervention.
After screening 638 articles, we identified 47 papers that met our inclusion and exclusion criteria. The most common procedure evaluated was CABG and PCI; 46 of the studies focused on these 2 procedures. Almost all of the articles reported a different metric for SDH/social deprivation (41 different metrics); despite this, all of the metrics showed a consistent relationship with worse outcomes associated with greater degrees of SDH/deprivation. Only 9 reported on the individual domains of SDH/social deprivation; 3 studies showed a discordant relationship.
Although our systematic review identified numerous articles evaluating the relationship between SDH/social deprivation in cardiovascular disease, there was substantial heterogeneity in which metric was used and how it was reported. This reinforces the need for standards as to the best metrics for SDH/social deprivation as well as best practices for reporting.
La littérature médicale sur les chirurgies cardiovasculaires est limitée par l’absence de consensus sur les meilleures mesures à utiliser pour les déterminants sociaux de la santé ou du dénuement social et sur le moyen de les déclarer : en une seule mesure ou séparément, selon le domaine.
Une revue systématique de la littérature sur les chirurgies et procédures cardiovasculaires a été réalisée, et portait sur les articles publiés entre le 1er janvier 2010 et le 31 décembre 2023 qui abordaient la relation entre les issues de santé après une intervention ou chirurgie cardiovasculaire et les déterminants sociaux de la santé ou le dénuement social. Les interventions et chirurgies cardiovasculaires d’intérêt comprenaient le pontage aortocoronarien, l’intervention coronarienne percutanée (ICP), le remplacement ou la réparation d’une valve et l’implantation valvulaire aortique par cathéter.
Après avoir passé au crible 638 articles, nous avons recensé 47 articles qui répondaient à nos critères d’inclusion et motifs d’exclusion. Les interventions les plus couramment évaluées étaient le pontage aortocoronarien et l’ICP; 46 études se concentraient sur ces deux interventions. Presque tous les articles utilisaient une mesure différente des déterminants sociaux de la santé ou du dénuement social (41 paramètres différents); malgré tout, toutes les mesures montraient une relation cohérente entre les issues négatives et un plus haut degré de dénuement social ou des déterminants sociaux de la santé défavorables. Seules 9 études ont signalé les domaines individuels des mesures des déterminants sociaux de la santé ou du dénouement social; 3 ont montré une relation conflictuelle.
Même si notre revue systématique a permis de recenser de nombreux articles évaluant la relation entre les déterminants sociaux de la santé ou le dénuement social et la maladie cardiovasculaire, on a constaté une hétérogénéité importante dans les paramètres utilisés et dans la déclaration des mesures. Cette observation réitère la nécessité de normaliser les mesures des déterminants sociaux de la santé ou du dénuement social et d’élaborer des pratiques exemplaires dans la déclaration de ces mesures.
To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the ...nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog.
We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario.
Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508-174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval CI 46-145), with an estimated weekly throughput of 717 patients (95% CI 326-1367) requiring 719 operating room hours (95% CI 431-1038), 265 ward beds (95% CI 87-678) and 9 ICU beds (95% CI 4-20) per week.
The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.
Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic ...heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups.
To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD).
A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible.
Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies.
Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.
Graphical Abstract
Graphical abstract
Key concurrences and divergences of ESC/EACTS and ACC/AHA Guidelines. ACC/AHA, American College of Cardiology/American Heart Association; AS, aortic stenosis; ...AVR, aortic valve replacement; ESC/EACTS, European Society of Cardiology/European Association for Cardio-Thoracic Surgery; LVEF, left ventricular ejection fraction; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.
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.
Audio Abstract
10.1093/eurheartj/ehac803audio1
Audio Abstract
ehac803media1
6318549093112
The prognostic importance of high-density lipoprotein cholesterol (HDL-C) as a specific risk factor for cardiovascular (CV) disease has been challenged by recent clinical trials and genetic studies.
...This study sought to reappraise the association of HDL-C level with CV and non-CV mortality using a "big data" approach.
An observational cohort study was conducted using the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) dataset, which was created by linking together 17 different individual-level data sources. People were included if they were between 40 and 105 years old on January 1, 2008, living in Ontario, Canada, without previous CV conditions or severe comorbidities, and had an outpatient fasting cholesterol measurement in the year prior to the inception date. The primary outcome was cause-specific mortality.
A total of 631,762 individuals were included. The mean age of our cohort was 57.2 years, 55.4% were women, and mean HDL-C level was 55.2 mg/dl. There were 17,952 deaths during a mean follow-up of 4.9 ± 0.4 years. The overall all-cause mortality rate was 8.1 per 1,000 person-years for men and 6.6 per 1,000 person-years for women. Individuals with lower HDL-C levels were more likely to have low incomes, unhealthy lifestyle, higher triglycerides levels, other cardiac risk factors, and medical comorbidities. Individuals with lower HDL-C levels were independently associated with higher risk of CV, cancer, and other mortality compared with individuals in the reference ranges of HDL-C levels. In addition, individuals with higher HDL levels (>70 mg/dl in men, >90 mg/dl in women) had increased hazard of non-CV mortality.
Complex associations exist between HDL-C levels and sociodemographic, lifestyle, comorbidity factors, and mortality. HDL-C level is unlikely to represent a CV-specific risk factor given similarities in its associations with non-CV outcomes.
The aim of this study was to compare early and late outcomes between redo surgical aortic valve replacement (AVR) and valve-in-valve (ViV) transcatheter AVR.
Published studies to date comparing redo ...surgical AVR (RS) with ViV transcatheter AVR for failed biological prostheses have been small and limited to early outcomes.
Clinical and administrative databases for Ontario, Canada's most populous province, were linked to obtain patients undergoing ViV and RS for failed previous biological prostheses. Propensity score matching was performed to account for differences in baseline characteristics. Early outcomes were compared using the McNemar test. Late mortality was compared between the matched groups using a Cox proportional hazards model.
A total of 558 patients undergoing intervention for failed biological prostheses between March 31, 2008, and September 30, 2017, at 11 Ontario institutions (ViV, n = 214; RS, n = 344) were included. Patients who underwent ViV were older and had more comorbidities. Propensity matching on 27 variables yielded similar groups for comparison (n = 131 pairs). Mean time from initial AVR to RS or ViV was 8.6 ± 4.4 years and 11.3 ± 4.5 years, respectively. Thirty-day mortality was significantly lower with ViV compared with RS (absolute risk difference: -7.5%; 95% confidence interval: -12.6% to -2.3%). The rates of permanent pacemaker implantation and blood transfusions were also lower with ViV, as was length of stay. Survival at 5 years was higher with ViV (76.8% vs. 66.8%; hazard ratio: 0.55; 95% confidence interval: 0.30 to 0.99; p = 0.04).
ViV TAVR was associated with lower early mortality, morbidity, and length of hospital stay and with increased survival compared with RS and may be the preferred approach for the treatment of failed biological prostheses.
Readmission rates after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations have decreased in the United States since the implementation of the Hospital Readmissions Reduction ...Program.
This study was designed to examine the temporal trends of readmission and mortality after AMI and HF in Ontario, Canada, where reducing hospital readmissions has not had a policy incentive.
The cohort was comprised of AMI or HF patients 65 years of age or older who had been hospitalized from 2006 to 2017. Primary outcomes were 30-day readmission and post-discharge mortality. Secondary outcomes included in-hospital mortality, 30-day mortality from admission, and in-hospital mortality or 30-day mortality post-discharge. Adjusted monthly trends for each outcome were examined over the study period.
Our cohorts included 152,808 AMI and 223,283 HF patients. Age- and sex-standardized AMI hospitalization rates in Ontario declined 32% from 2006 to 2017 while HF hospitalization rates declined slightly (9.1%). For AMI, risk-adjusted 30-day readmission rates declined from 17.4% in 2006 to 14.7% in 2017. All AMI risk-adjusted mortality rates also declined from 2006 to 2017 with 30-day post-discharge mortality from 5.1% to 4.4%. For HF, overall risk-adjusted 30-day readmission was largely unchanged from 2006 to 2014 at 21.9%, followed by a decline to 20.8% in 2017. Risk-adjusted 30-day post-discharge mortality declined from 7.1% in 2006 to 6.6% in 2017.
The patterns of outcomes in Ontario are consistent with the United States for AMI, but diverge for HF. For AMI and HF, admissions, readmissions, and mortality rates declined over this period. The reasons for the country-specific patterns for HF need further exploration.
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