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Ueda D, Yamamoto A, Ehara S, Iwata S, Abo K, Walston SL, Matsumoto T, Shimazaki A, Yoshiyama M, Miki Y. Artificial intelligence-based detection of aortic stenosis from chest radiographs. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 3:20-28. [PMID: 36713993 PMCID: PMC9707887 DOI: 10.1093/ehjdh/ztab102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/16/2021] [Accepted: 11/30/2021] [Indexed: 02/01/2023]
Abstract
Aims We aimed to develop models to detect aortic stenosis (AS) from chest radiographs-one of the most basic imaging tests-with artificial intelligence. Methods and results We used 10 433 retrospectively collected digital chest radiographs from 5638 patients to train, validate, and test three deep learning models. Chest radiographs were collected from patients who had also undergone echocardiography at a single institution between July 2016 and May 2019. These were labelled from the corresponding echocardiography assessments as AS-positive or AS-negative. The radiographs were separated on a patient basis into training [8327 images from 4512 patients, mean age 65 ± (standard deviation) 15 years], validation (1041 images from 563 patients, mean age 65 ± 14 years), and test (1065 images from 563 patients, mean age 65 ± 14 years) datasets. The soft voting-based ensemble of the three developed models had the best overall performance for predicting AS with an area under the receiver operating characteristic curve, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 0.83 (95% confidence interval 0.77-0.88), 0.78 (0.67-0.86), 0.71 (0.68-0.73), 0.71 (0.68-0.74), 0.18 (0.14-0.23), and 0.97 (0.96-0.98), respectively, in the validation dataset and 0.83 (0.78-0.88), 0.83 (0.74-0.90), 0.69 (0.66-0.72), 0.71 (0.68-0.73), 0.23 (0.19-0.28), and 0.97 (0.96-0.98), respectively, in the test dataset. Conclusion Deep learning models using chest radiographs have the potential to differentiate between radiographs of patients with and without AS. Lay Summary We created artificial intelligence (AI) models using deep learning to identify aortic stenosis (AS) from chest radiographs. Three AI models were developed and evaluated with 10 433 retrospectively collected radiographs and labelled from echocardiography reports. The ensemble AI model could detect AS in a test dataset with an area under the receiver operating characteristic curve of 0.83 (95% confidence interval 0.78-0.88). Since chest radiography is a cost-effective and widely available imaging test, our model can provide an additive resource for the detection of AS.
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Affiliation(s)
- Daiju Ueda
- Corresponding author. Tel: +81 6 6645 3831, Fax: +81 6 6646 6655,
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shoichi Ehara
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shinichi Iwata
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Koji Abo
- Central Clinical Laboratory, Osaka City University Hospital, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shannon L Walston
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Toshimasa Matsumoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Akitoshi Shimazaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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Sturm RC, Harrison J, Tandar A. Frailty and TAVR-Is this the hard-to-define glass ceiling? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 34:61-62. [PMID: 34810114 DOI: 10.1016/j.carrev.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Robert C Sturm
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America
| | - Jonathan Harrison
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America
| | - Anwar Tandar
- Division Cardiovascular Medicine, University of Utah School of Medicine, United States of America.
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Boskovski MT, Nguyen TC, McCabe JM, Kaneko T. Outcomes of Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis. JAMA Surg 2020; 155:69-77. [DOI: 10.1001/jamasurg.2019.4449] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Marko T. Boskovski
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tom C. Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas at Houston
| | | | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Abstract
There is consensus on important aspects of managing heart valve disease. Despite this, many patients are managed by general physicians or cardiologists without specialist competencies in valve disease, which leads to suboptimal outcomes. Multidisciplinary heart valve clinics bring together cardiologists, surgeons, nurses, and in some countries scientists to deliver expert guidelines and experience-driven optimal care. Patients are referred at the optimal time for interventions at heart valve centers, defined by strict standards of facilities and processes. Valve networks link valve clinic, heart valve center, and the community to improve the passage of patients at every level of care.
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Affiliation(s)
- John B Chambers
- Cardiothoracic Center, Guy's and St Thomas' Hospitals, Westminster Bridge Road, London SE1 7EH, UK.
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Rue de l'hôpital 1, 4000 Liège, Belgium
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Hengstenberg C, Thoenes M, Bramlage P, Siller-Matula J, Mascherbauer J. Aortic valve stenosis awareness in Austria-results of a nationwide survey in 1001 subjects. Wien Med Wochenschr 2019; 170:141-149. [PMID: 31541366 PMCID: PMC7098927 DOI: 10.1007/s10354-019-00708-2] [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] [Received: 03/27/2019] [Accepted: 07/16/2019] [Indexed: 12/05/2022]
Abstract
Despite the prognostic significance of severe aortic valve stenosis, knowledge is limited in the general population. To document the status quo for Austria, knowledge about valvular heart disease/aortic valve stenosis was documented in 1001 participants >60 years of age. 6.7% of respondents were knowledgeable of aortic valve stenosis, with 1.6% being concerned about the condition (24.1% cancer, 18.8% Alzheimer’s disease, 15.1% stroke). 29.5% were familiar with valvular heart disease (76.7% heart attack, 36.9% stroke). Only 1/3 reported auscultation by their general practitioner (GP) at least every third visit. Typical symptoms of aortic valve stenosis were likely to be reported by 50%. After exposure to further information on aortic valve stenosis, only 20% reported to be more concerned and ready to obtain more disease-related information. Awareness of surgical and catheter-based treatment options was claimed by 77% of respondents. Awareness campaigns on valvular heart disease are warranted to improve patient care in Austria.
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Affiliation(s)
- Christian Hengstenberg
- Department of Internal Medicine, Division of Cardiology, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Jolanta Siller-Matula
- Department of Internal Medicine, Division of Cardiology, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine, Division of Cardiology, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Thoenes M, Bramlage P, Zamorano P, Messika-Zeitoun D, Wendt D, Kasel M, Kurucova J, Steeds RP. Patient screening for early detection of aortic stenosis (AS)-review of current practice and future perspectives. J Thorac Dis 2018; 10:5584-5594. [PMID: 30416809 DOI: 10.21037/jtd.2018.09.02] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In Europe, approximately one million people over 75 years suffer from severe aortic stenosis (AS), one of the most serious and most common valve diseases, and this disease burden is increasing with the aging population. A diagnosis of severe symptomatic AS is associated with an average life expectancy of 2-3 years and necessitates a timely valve intervention. Guidelines for valve replacement therapy have been established but only a proportion of patients with symptomatic AS actually receive this life-saving treatment. The decision for valve intervention in asymptomatic patients with severe AS is often more challenging and likely results in fewer patients receiving treatment in comparison to their symptomatic counterparts. This article reviews the epidemiology and clinical manifestations of AS, the associated economic burden of AS to the healthcare system, the diagnosis of AS and the possible mechanisms for the introduction of routine screening in elderly patients. Elderly patients typically visit healthcare providers more frequently than younger patients, thereby providing increased opportunities for ad hoc AS screening and this, along with raising patient awareness of the symptoms of AS, has the potential to result in the earlier diagnosis and treatment of AS and increased patient survival.
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Affiliation(s)
- Martin Thoenes
- Léman Research Institute, Schaffhausen am Rheinfall, Switzerland.,Edwards Lifesciences, Nyon, Switzerland
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | | | - Daniel Wendt
- Klinik für Thorax- und Kardiovaskuläre Chirurgie, Westdeutsches Herzzentrum Essen, Universitätsklinikum Essen, Essen, Germany
| | | | | | - Richard P Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:593-601. [PMID: 27605940 PMCID: PMC4996834 DOI: 10.11909/j.issn.1671-5411.2016.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes. Methods Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored. Results Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis. Conclusions Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.
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Hu K, Wan Y, Hong T, Lu SY, Guo CF, Li J, Wang CS. Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases. Int Heart J 2016; 57:434-40. [PMID: 27396559 DOI: 10.1536/ihj.16-027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases.A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated.Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series.Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.
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Affiliation(s)
- Kui Hu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, The Shanghai Institute of Cardiovascular Diseases
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10
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Abstract
PURPOSE OF REVIEW Aortic stenosis is the most frequent valvular heart disease in the USA, and aortic valve replacement remains the only definitive treatment. For patients who cannot have surgery or who are at an increased risk for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) has become an established treatment option. New technological developments in valve design will make TAVR available to an even wider group of patients. This review describes the TAVR procedure and its critical stages. RECENT FINDINGS To ensure that patients with aortic stenosis receive the best treatment option for them, evaluation by a multispecialty heart team is essential. In addition to determining TAVR vs. SAVR, the 'heart team' approach should be used for determining the access site, type, and size of valve, imaging modalities, and the type of anesthetic used for the procedure. Ability to perform TAVR in the cath lab under local anesthesia shortens the duration and lowers the cost of the procedure, and makes it even more attractive. SUMMARY TAVR is a treatment option for patients who are at an increased risk for SAVR. Evolving technology will likely expand the patient population eligible for this type of treatment in the very near future. Multidisciplinary heart team is essential in improving current techniques and patient selection, as well as evaluating new technologies.
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Simon ACR, Schopman JE, Hoekstra JBL, Abu-Hanna A, Gerdes VEA, Peek N, Holleman F. Factors that drive insulin-dosing decisions of diabetes care providers: a vignette-based study in the Netherlands. Diabet Med 2015; 32:69-77. [PMID: 25204362 DOI: 10.1111/dme.12586] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/09/2014] [Accepted: 09/04/2014] [Indexed: 01/09/2023]
Abstract
AIM To test how certain patient factors would influence the decision of Dutch care providers regarding insulin dose adjustments. We hypothesize that some of these decisions would diverge from recent evidence and consensus statements. METHODS We developed narrative vignettes describing clinical scenarios of patients receiving basal insulin therapy. For each vignette, the respondents were asked to indicate whether they would advise a change in insulin dose. A total of 520 paper questionnaires were distributed among physicians and nurses in primary and secondary care in the Netherlands. Multivariate linear and logistic regression analyses were performed to identify factors associated with dosing decisions. RESULTS A total of 190 (37%) questionnaires were returned. In cases of a severe rather than mild hypoglycaemic event, care providers were nearly five times more likely to decrease the dose (odds ratio 4.77, 95% CI 1.65-13.75). Care providers were six times more likely to increase the dose when the patient's current dose was low (30 units) rather than high (90 units) (odds ratio 6.38, 95% CI 3.04-13.37). The plasma glucose concentration during a hypoglycaemic event and a known history of cardiovascular disease did not influence the care providers' dosing decisions. CONCLUSION Evidence regarding the optimum insulin titration is not always translated into clinical practice. When formulating guidelines, misconceptions should be identified and addressed.
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Affiliation(s)
- A C R Simon
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands; Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands
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12
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Freeman M, Webb JG. Edwards SAPIEN™ and Edwards SAPIEN XT™ transcatheter heart valves for the treatment of severe aortic stenosis. Expert Rev Med Devices 2014; 9:563-9. [DOI: 10.1586/erd.12.53] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Green P, Rosner GF, Schwartz A. Valvular heart disease in older adults: evolving technology to meet the needs of aging patients. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ahe.13.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Valvular heart disease is associated with aging and the incidence is increasing as the population ages. Aortic stenosis and mitral regurgitation represent the majority of valvular disease in older adults. Severe valvular disease is associated with the development of heart failure, arrhythmia and death. Unfortunately, medical therapy is ineffective for the treatment of severe symptomatic valvular disease. As a result of advances in surgical techniques and catheter-based technologies, older adults who were once deemed ‘too old/sick’ are now being offered definitive treatment. However, the presence of comorbidities and frailty in the elderly make patient selection difficult and prediction of overall response to therapy less reliable compared with younger patients. In the elderly, goals of therapy may differ, with an emphasis placed on quality of life, functionality, maintaining independence and palliation of severe symptoms rather than increased longevity. We review the epidemiology and treatment approaches for valvular heart disease in older adults.
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Affiliation(s)
- Philip Green
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, 177 Fort Washington Avenue, Milstein Building, Room 5-435, NY 10032, USA
| | - Gregg F Rosner
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, 177 Fort Washington Avenue, Milstein Building, Room 5-435, NY 10032, USA
| | - Allan Schwartz
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, 177 Fort Washington Avenue, Milstein Building, Room 5-435, NY 10032, USA.
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Chambers JB, Ray S, Prendergast B, Taggart D, Westaby S, Grothier L, Arden C, Wilson J, Campbell B, Sandoe J, Gohlke-Bärwolf C, Mestres CA, Rosenhek R, Otto C. Specialist valve clinics: recommendations from the British Heart Valve Society working group on improving quality in the delivery of care for patients with heart valve disease. Heart 2013; 99:1714-6. [PMID: 23532202 DOI: 10.1136/heartjnl-2013-303754] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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van Geldorp MWA, Heuvelman HJ, Kappetein AP, Busschbach JJV, Cohen DJ, Takkenberg JJM, Bogers AJJC. Quality of life among patients with severe aortic stenosis. Neth Heart J 2012; 21:21-7. [PMID: 23229811 DOI: 10.1007/s12471-012-0364-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The disease burden of patients with severe aortic stenosis is not often explored, while the incidence is increasing and many patients who have an indication for aortic valve replacement are not referred for surgery. We studied the quality of life of 191 patients with severe aortic stenosis, hypothesising that symptomatic patients have a far worse quality of life than the general population, which could enforce the indication for surgery. METHODS The SF-36v2 Health Survey was completed by 191 consecutive patients with symptomatic or asymptomatic severe aortic stenosis. RESULTS Asymptomatic patients (n = 59) had health scores comparable with the general Dutch population but symptomatic patients (n = 132) scored significantly lower across different age categories. Physical functioning, general health and vitality were impaired, as well as social functioning and emotional well-being. There was no relation between degree of stenosis and physical or mental health scores. CONCLUSIONS Both physical and emotional problems have a major impact on normal daily life and social functioning of symptomatic patients with severe aortic stenosis, regardless of age. If the aortic stenosis is above the 'severe' threshold, the degree of stenosis does not predict disease burden. These results encourage to reconsider a conservative approach in symptomatic patients with severe aortic stenosis. Using the SF-36v2 Health Survey together with this study, an individual patient's quality of life profile can be assessed and compared with the patient group or with the general population. This can assist in decision making for the individual patient.
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Affiliation(s)
- M W A van Geldorp
- Department of Cardio-thoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands,
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Clinical course of patients diagnosed with severe aortic stenosis in the Rotterdam area: insights from the AVARIJN study. Neth Heart J 2012; 20:487-93. [PMID: 22864980 DOI: 10.1007/s12471-012-0309-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To prospectively evaluate the clinical course of patients with severe aortic stenosis (AS) and identify factors associated with treatment selection and patient outcome. METHODS Patients diagnosed with severe AS in the Rotterdam area were included between June 2006 and May 2009. Patient characteristics, echocardiogram, brain natriuretic peptide (NT-proBNP), and treatment strategy were assessed at baseline, and after 6, 12, and 24 months. Endpoints were aortic valve replacement (AVR) / transcatheter aortic valve implantation (TAVI) and death. RESULTS The study population comprised 191 patients, 132 were symptomatic and 59 asymptomatic at study entry. Two-year cumulative survival of symptomatic patients was 89.8 % (95 % CI 79.8-95.0 %) after AVR/TAVI and 72.6 % (95 % CI 59.7-82.0 %) with conservative treatment. Two-year cumulative survival of asymptomatic patients was 91.5 % (95 % CI 80.8-96.4 %). Two-year cumulative incidence of AVR/TAVI was 55.9 % (95 % CI 47.5-63.5 %) in symptomatic patients. Sixty-eight percent of asymptomatic patients developed symptoms, median time to symptoms was 13 months; AVR/TAVI cumulative incidence was 38.3 % (95 % CI 23.1-53.3 %). Elderly symptomatic patients with multiple comorbidities were more likely to receive conservative treatment. CONCLUSIONS In contemporary Dutch practice many symptomatic patients do not receive invasive treatment of severe AS. Two-thirds of asymptomatic patients develop symptoms within 2 years, illustrating the progressive nature of severe AS. Treatment optimisation may be achieved through careful individualised assessment in a multidisciplinary setting.
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Holmes DR, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JD, Harrington RA, Bhatt DL, Ferrari VA, Fisher JD, Garcia MJ, Gardner TJ, Gentile F, Gilson MF, Hernandez AF, Jacobs AK, Kaul S, Linderbaum JA, Moliterno DJ, Weitz HH. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement: developed in collabration with the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Mended Hearts, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Thorac Cardiovasc Surg 2012; 144:e29-84. [PMID: 22898522 DOI: 10.1016/j.jtcvs.2012.03.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Schouten HJ, van Ginkel S, Koek H(D, Geersing GJ, Oudega R, Moons KG, van Delden J(H. Non-Diagnosis Decisions and Non-Treatment Decisions in Elderly Patients With Cardiovascular Diseases, Do They Differ? – A Systematic Review. J Am Med Dir Assoc 2012; 13:682-7. [PMID: 22705033 DOI: 10.1016/j.jamda.2012.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/14/2012] [Accepted: 05/14/2012] [Indexed: 11/25/2022]
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Forrest JK. Transcatheter aortic valve replacement: design, clinical application, and future challenges. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2012; 85:239-47. [PMID: 22737052 PMCID: PMC3375667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a new technology that recently has been shown to improve survival and quality of life in patients with severe symptomatic aortic stenosis who are not surgical candidates. The development and design of transcatheter valves has been ongoing for the past 20 years, and TAVR has now been approved by the FDA as a treatment for aortic stenosis in patients who are not surgical candidates. In the United States, there are currently two transcatheter valves available: the Edwards Sapien Valve and the Medtronic CoreValve. While similar in some design elements, they also have characteristic differences that affect both the mechanism of delivery as well as performance in patients. This review aims to take a closer look at the development of this new technology, review the published clinical results, and look toward the future of transcatheter valve therapeutics and the challenges therein.
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Holmes DR, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JD, Harrington RA, Bhatt DL, Ferrari VA, Fisher JD, Garcia MJ, Gardner TJ, Gentile F, Gilson MF, Hernandez AF, Jacobs AK, Kaul S, Linderbaum JA, Moliterno DJ, Weitz HH. 2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement. Catheter Cardiovasc Interv 2012; 79:1023-82. [DOI: 10.1002/ccd.24351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Holmes DR, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JD. 2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2012; 93:1340-95. [PMID: 22300625 DOI: 10.1016/j.athoracsur.2012.01.084] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 01/26/2012] [Accepted: 01/26/2012] [Indexed: 12/20/2022]
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22
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Holmes DR, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JD. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59:1200-54. [PMID: 22300974 DOI: 10.1016/j.jacc.2012.01.001] [Citation(s) in RCA: 544] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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23
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García E, Hernández-Antolín R, Dutary J, Paulo M, Heredia J, Guerrero F, Rodríguez J, Gorgadze T, Almería C, Macaya C. [Rapidly evolving techniques for structural heart disease interventions]. Rev Esp Cardiol 2011; 64 Suppl 2:19-27. [PMID: 21928484 DOI: 10.1016/j.recesp.2011.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Structural heart disease interventions are the transcatheter techniques used for treating non-coronary heart disease. In recent years, these techniques have generated considerable interest even though they still comprise only a small percentage of the total volume of interventions performed in interventional cardiology departments. The level of interest in these techniques is high probably because their application is characterized by a number of special features: a) the need for multidisciplinary teams; b) the need for specialized education and training; c) the requirement for special skills developed through education and experience, and d) the limited number of referral centers at present. This article describes four specific techniques: a) percutaneous closure of perivalvular leaks; b) percutaneous left atrial appendage obliteration; c) percutaneous treatment of mitral regurgitation, and d) transcatheter implantation of prosthetic aortic valves. We explore the rationale for using the technique, the specific procedures involved and the results obtained.
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Affiliation(s)
- Eulogio García
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, España.
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24
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Nathan H, Bridges JFP, Schulick RD, Cameron AM, Hirose K, Edil BH, Wolfgang CL, Segev DL, Choti MA, Pawlik TM. Understanding surgical decision making in early hepatocellular carcinoma. J Clin Oncol 2011; 29:619-25. [PMID: 21205759 DOI: 10.1200/jco.2010.30.8650] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE The choice between liver transplantation (LT), liver resection (LR), and radiofrequency ablation (RFA) as initial therapy for early hepatocellular carcinoma (HCC) is controversial, yet little is known about how surgeons choose therapy for individual patients. We sought to quantify the impact of both clinical factors and surgeon specialty on surgical decision making in early HCC by using conjoint analysis. METHODS Surgeons with an interest in liver surgery were invited to complete a Web-based survey including 10 case scenarios. Choice of therapy was then analyzed by using regression models that included both clinical factors and surgeon specialty (non-LT v LT). RESULTS When assessing early HCC occurrences, non-LT surgeons (50% LR; 41% LT; 9% RFA) made significantly different recommendations compared with LT surgeons (63% LT; 31% LR; 6% RFA; P < .001). Clinical factors, including tumor number and size, type of resection required, and platelet count, had significant effects on the choice between LR, LT, and RFA. After adjusting for clinical factors, non-LT surgeons remained more likely than LT surgeons to choose LR compared with LT (relative risk ratio [RRR], 2.67). When the weight of each clinical factor was allowed to vary by surgeon specialty, the residual independent effect of surgeon specialty on the decision between LR and LT was negligible (RRR, 0.93). CONCLUSION The impact of surgeon specialty on choice of therapy for early HCC is stronger than that of some clinical factors. However, the influence of surgeon specialty does not merely reflect an across-the-board preference for one therapy over another. Rather, certain clinical factors are weighed differently by surgeons in different specialties.
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Affiliation(s)
- Hari Nathan
- The Johns Hopkins Hospital, 600 N Wolfe St, Harvey 611, Baltimore, MD 21287, USA
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25
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Layland JJ, Bell B, Mullany D, Walters DL. Percutaneous management of aortic stenosis in high‐risk patients. Med J Aust 2010; 192:520-5. [DOI: 10.5694/j.1326-5377.2010.tb03616.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 12/22/2009] [Indexed: 11/17/2022]
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26
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Henderson A. Surgical report cards: the myth and the reality. Monash Bioeth Rev 2009; 28:1-20. [PMID: 20131525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
There seems no good reason for doctors to work in secret. Individual users of healthcare and the community in general, which ultimately bears the cost, are perfectly entitled to know how their health services and health providers are performing. The promulgation of surgical report cards has been hailed by some as a liberating step in the right direction. This paper seeks to analyse, from a clinician's perspective, the evolution and limitations of report cards. Ultimately, the importance of report cards will not be their immediate utility, which is minimal, but as a first step in a much wider and far more important debate about how we meaningfully measure the quality of health services and providers (including managers and bureaucrats), the likely cost of such an enterprise, how much we are willing and able to pay and how we reconcile the competing needs of information versus clinical and preventive care when all are competing for the same and inadequate pool of resources.
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27
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Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement? Eur J Cardiothorac Surg 2009; 35:953-7; discussion 957. [DOI: 10.1016/j.ejcts.2009.01.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 01/21/2009] [Accepted: 01/27/2009] [Indexed: 11/24/2022] Open
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28
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Bachmann LM, Mühleisen A, Bock A, ter Riet G, Held U, Kessels AGH. Vignette studies of medical choice and judgement to study caregivers' medical decision behaviour: systematic review. BMC Med Res Methodol 2008; 8:50. [PMID: 18664302 PMCID: PMC2515847 DOI: 10.1186/1471-2288-8-50] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 07/30/2008] [Indexed: 05/25/2023] Open
Abstract
Background Vignette studies of medical choice and judgement have gained popularity in the medical literature. Originally developed in mathematical psychology they can be used to evaluate physicians' behaviour in the setting of diagnostic testing or treatment decisions. We provide an overview of the use, objectives and methodology of these studies in the medical field. Methods Systematic review. We searched in electronic databases; reference lists of included studies. We included studies that examined medical decisions of physicians, nurses or medical students using cue weightings from answers to structured vignettes. Two reviewers scrutinized abstracts and examined full text copies of potentially eligible studies. The aim of the included studies, the type of clinical decision, the number of participants, some technical aspects, and the type of statistical analysis were extracted in duplicate and discrepancies were resolved by consensus. Results 30 reports published between 1983 and 2005 fulfilled the inclusion criteria. 22 studies (73%) reported on treatment decisions and 27 (90%) explored the variation of decisions among experts. Nine studies (30%) described differences in decisions between groups of caregivers and ten studies (33%) described the decision behaviour of only one group. Only six studies (20%) compared decision behaviour against an empirical reference of a correct decision. The median number of considered attributes was 6.5 (IQR 4–9), the median number of vignettes was 27 (IQR 16–40). In 17 studies, decision makers had to rate the relative importance of a given vignette; in six studies they had to assign a probability to each vignette. Only ten studies (33%) applied a statistical procedure to account for correlated data. Conclusion Various studies of medical choice and judgement have been performed to depict weightings of the value of clinical information from answers to structured vignettes of care givers. We found that the design and analysis methods used in current applications vary considerably and could be improved in a large number of cases.
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Affiliation(s)
- Lucas M Bachmann
- Horten Centre, University of Zurich, Bolleystrasse 40, CH-8091 Zurich, Switzerland.
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29
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Kojodjojo P, Gohil N, Barker D, Youssefi P, Salukhe TV, Choong A, Koa-Wing M, Bayliss J, Hackett DR, Khan MA. Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: impact of patient's choice of refusing aortic valve replacement on survival. QJM 2008; 101:567-73. [PMID: 18443003 DOI: 10.1093/qjmed/hcn052] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80. AIM To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR. DESIGN Cohort study. METHODS Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of medical records and telephone interviews. The primary endpoint was all-cause mortality. RESULTS A total of 103 patients (86.0 +/- 4.2 years, 41% male) were identified and no patient was lost during follow-up. In Group A (n = 17), all 15 patients who underwent AVR were alive after 3.6 +/- 1.4 years follow-up and 2 died whilst awaiting AVR. Seventy-four percent of Group B (n = 24) and 76% of Group C (n = 62) died during follow-up. Group A had significantly better survival than B and C. (P < 0.01) Amongst patients fit for AVR with similar operative risks (Groups A and B), refusal to undergo surgery (hazard ratio 12.61, P = 0.001) was the only predictor of mortality in a multivariate model. CONCLUSION For elderly AS patients fit for surgery, the patient's decision to refuse AVR is associated with a >12-fold increase in mortality risk. These findings have significant implications for informed decision-making when managing the fit, elderly patient with AS.
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Affiliation(s)
- P Kojodjojo
- Department of Cardiology, Hemel Hempstead General Hospital, Hillfield Road, Hertfordshire HP24AD, UK.
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30
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Bose AK, Aitchison JD, Dark JH. Aortic valve replacement in octogenarians. J Cardiothorac Surg 2007; 2:33. [PMID: 17629905 PMCID: PMC1947977 DOI: 10.1186/1749-8090-2-33] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Accepted: 07/13/2007] [Indexed: 11/13/2022] Open
Abstract
Background and Aims As our population ages and life expectancy increases the number of people aged over 80 and more referred for cardiac surgery is growing. This study sought to identify the outcome of aortic valve replacement (AVR) in octogenarians. Methods 68 patients aged 80 years or more underwent AVR at the Freeman Hospital, between April 2001 and April 2004. A retrospective review of the notes and outcomes from the patients' GP and the NHS strategic tracking service was performed. 54% (37) underwent isolated AVR whilst 46% (31) underwent combined AVR and CABG. Results Follow up was 100% complete. The mean age was 83.1 ± s.d. 2.9 years, a mean gradient of 83 ± s.d. 31 mmHg and mean AVA of 0.56 cm2. The mean additive EuroSCORE was 8.6 ± s.d. 1.2, the logistic EuroSCORE mean 12.0 ± s.d. 5.9. In hospital 30 day mortality was 13 %. Survival was 80% at 1 year and 78% at 2 years. Median follow up was for 712 days. Stepwise logistic regression identified chronic obstructive airways disease as an independent predictor of mortality (p < 0.05). Survival was not adversely affected by the addition of coronary artery bypass grafts to aortic valve replacement, the presence of peripheral vascular disease, hypertension or diabetes. In this study duration of cross clamp or bypass time were not found to reach significance as independent predictors of mortality. Conclusion Our study demonstrates that the operative mortality for AVR in the over eighties is good, whilst the mid to long term outcome is excellent There is a very low attrition rate with those undergoing the procedure living as long than their age matched population. This study confirms AVR is a safe, acceptable treatment for octogenarians with excellent mid term outcomes.
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Affiliation(s)
- Amal K Bose
- Department of Cardiothoracic Surgery, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, UK
| | - James D Aitchison
- Department of Cardiothoracic Surgery, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, UK
| | - John H Dark
- Department of Cardiothoracic Surgery, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, UK
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Iung B, Cachier A, Baron G, Messika-Zeitoun D, Delahaye F, Tornos P, Gohlke-Bärwolf C, Boersma E, Ravaud P, Vahanian A. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J 2005; 26:2714-20. [PMID: 16141261 DOI: 10.1093/eurheartj/ehi471] [Citation(s) in RCA: 708] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To analyse decision-making in elderly patients with severe, symptomatic aortic stenosis (AS). METHODS AND RESULTS In the Euro Heart Survey on valvular heart disease, 216 patients aged > or =75 had severe AS (valve area < or =0.6 cm(2)/m(2) body surface area or mean gradient > or =50 mmHg) and angina or New York Heart Association class III or IV. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 72 patients (33%). In multivariable analysis, left ventricular (LV) ejection fraction [OR = 2.27, 95% CI (1.32-3.97) for ejection fraction 30-50, OR = 5.15, 95% CI (1.73-15.35) for ejection fraction < or =30 vs. >50%, P = 0.003] and age [OR = 1.84, 95% CI (1.18-2.89) for 80-85 years, OR=3.38, 95% CI (1.38-8.27) for > or =85 vs. 75-80 years, P = 0.008] were significantly associated with the decision not to operate; however, the Charlson comorbidity index was not [OR = 1.72, 95% CI (0.83-3.50), P = 0.14 for index > or =2 vs. <2]. Neurological dysfunction was the only comorbidity significantly linked with the decision not to operate. CONCLUSION Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.
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Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, AP-HP, Paris, France.
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32
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Bouma BJ, van der Meulen JHP, van den Brink RBA, Smidts A, Cheriex EC, Hamer HP, Arnold AER, Zwinderman AH, Lie KI, Tijssen JGP. Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis. J Clin Epidemiol 2004; 57:815-23. [PMID: 15485734 DOI: 10.1016/j.jclinepi.2003.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach. STUDY DESIGN AND SETTING We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals. RESULTS 34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment. CONCLUSION Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.
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Affiliation(s)
- B J Bouma
- Department of Cardiology, Academic Medical Centre-University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.
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Rodríguez R, Torrents A, García P, Ribera A, Permanyer G, Moradi M, Dousset P, Igual A, Murtra M. [Cardiac surgery in elderly patients]. Rev Esp Cardiol 2002; 55:1159-68. [PMID: 12423573 DOI: 10.1016/s0300-8932(02)76779-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The morbimortality of elderly patients, (age 70 years or older), who underwent surgery for valvular and coronary artery disease in the last 17 years was analyzed. PATIENTS AND METHOD A total of 1,305 patients (654 valvular, 531 coronary and 120 combined) operated from January 1985 to December 2000 were retrospectively studied. Mean age was 73.7 years. We analyzed the progression of the pathology, comorbidity, and results. A second retrospective analysis was made of patients who underwent surgery in the last three years (436 patients) to determine the relation between preoperative comorbidity and postoperative evolution. RESULTS The mean hospital mortality was 16% (18% valvular, 11% coronary artery, and 23% combined). In the last three years this mortality was reduced to 11% (15.17, 6.26, and 16.18%, respectively) despite an increase in comorbidity. Comorbidity and complications increased with age (p < 0.05). Mean hospital stay was 15.5 days and the stay in intensive/semi-intensive care was 5 days. Independent risk factors of postoperative complications were creatinine levels > 2 mg/dl, combined surgery, and prior surgery. Predictors of death were prior surgery, valvular surgery, and combined surgery, with a clear tendency in the case of obesity. The presence of any complication in the postoperative period (renal or respiratory failure, infections, or myocardial infarction) was an independent predictor of mortality. Off-pump coronary surgery reduced mortality. In recent years, the mortality of patients operated without extracorporeal circulation has decreased from 5.71% to 4% for those who underwent extracorporeal circulation. CONCLUSIONS Nowadays, cardiac surgery in older patients accounts for more than 30% of our surgical activity. Mortality is being controlled although comorbidity is increasing. The difference with respect to younger people is due to comorbidity (creatinine > 2 mg/dl, combined surgery, and previous surgery) and the higher probability of complications (infections, renal, and respiratory complications), which worsens prognosis. We believe that off-pump coronary surgery helps to improve results.
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Affiliation(s)
- Rafael Rodríguez
- Servicio de Cirugía cardíaca. Hospital Vall d'Hebron. Barcelona. España.
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Brunvand H, Offstad J, Nitter-Hauge S, Svennevig JL. Coronary artery bypass grafting combined with aortic valve replacement in healthy octogenarians does not increase postoperative risk. SCAND CARDIOVASC J 2002; 36:297-301. [PMID: 12470398 DOI: 10.1080/140174302320774519] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Critical aortic stenosis with or without coronary artery disease is increasingly common in octogenarians. Surgery is the treatment of choice, but indications and results of aortic valve replacement (AVR), particularly when combined with coronary artery bypass grafting (CABG) are debated. We investigated whether the combined procedure of AVR and CABG increased postoperative risk compared with isolated AVR in otherwise healthy octogenarians. DESIGN In the period 1994-1998, AVR was performed in 94 patients above 80 years, the majority in NYHA class III and IV. Combined AVR and CABG was performed in 52/94 patients. The patients were studied retrospectively by collecting data from hospital records and followed for 0-7 years. RESULTS Mean age was 82 +/- 2.3 years, sex (male/female) 33/61, left ventricular ejection fraction 70 +/- 18%, transvalvular peak pressure gradient 63 +/- 20 mmHg and aortic valve area 0.5 +/- 0.2 cm(2). Early mortality (< 30 days) was 4/42 (9.5%) after AVR and 4/52 (7.6%) after AVR and CABG (p = NS between groups). Three-year survival was 33/42 (78.5%) after AVR and 42/52 (80.7%) after AVR and CABG (p = NS between groups). CONCLUSION AVR with concomitant CABG in octogenarians with aortic stenosis who are otherwise healthy, may be performed without increased risk.
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Affiliation(s)
- Harald Brunvand
- Department of Cardiology, Rikshospitalet, University of Oslo, Norway.
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Brose S, Autschbach R, Engel M, Rauch T, Rauch FW. [Patient adapted valve selection: biological vs. mechanical heart valve replacement in aortic valve diseases]. ACTA ACUST UNITED AC 2001; 90:48-57. [PMID: 24445788 DOI: 10.1007/s003920170008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Since the first aortic valve replacement performed by Harken in 1960, the operation of aortic valve disease by replacing the native valve with a heart valve prosthesis has become one of the most frequently performed procedures in cardiac surgery. For valve replacement there are biological (xenografts and homografts) and mechanical heart valve prostheses available. When choosing the most suitable prosthesis the limited durability of a biological prosthesis and the risks of lifelong anticoagulation for a mechanical prosthesis have to be balanced.In this article the indication for operation of aortic valve stenosis and aortic regurgitation are discussed first. Based on the literature of the last 2 years the advantages and disadvantages of mechanical and biological heart valve prostheses (xenograft, homograft and ROSS procedure) are discussed. In addition rarely used techniques like aortic valve reconstruction are presented.Due to the fact that a biological prosthesis has a durability of 12-15 years and the risk of bleeding complications under anticoagulation grows with increasing age, the choice of a biological prosthesis can be recommended from the age of 65 years. Results of long-term studies at to whether this limit can be diminished by using a stentless biological prosthesis have to be awaited.
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Affiliation(s)
- S Brose
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Klinikum RWTH Aachen, Pauwelstr. 30, 52074, Aachen, Germany,
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