马涵萍
中国医学科学院阜外医院
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).
BMJ open 2023
BACKGROUND:With increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by the surgeon impact the outcomes, we compared the outcomes between CABGs performed first versus those performed after prior procedures, separately for on-pump and off-pump CABGs as they differed in technical complexity.METHODS:We conducted a retrospective cohort study of patients undergoing isolated CABG in China from January 2013 to December 2018. Patients were categorised as undergoing on-pump and off-pump CABGs. Outcomes of the procedures performed first in primary surgeons' daily schedule (first procedure) were compared with subsequent ones (non-first procedure). The primary outcome was an adverse events composite (AEC) defined as the number of adverse events, including in-hospital mortality, myocardial infarction, stroke, acute kidney injury and reoperation. Secondary outcomes were the individual components of the primary outcome, presented as binary variables. Mixed-effects models were used, adjusting for patient and surgeon-level characteristics and year of surgery.RESULTS:Among 21 866 patients, 10 109 (16.1% as non-first) underwent on-pump and 11 757 (29.6% as non-first) off-pump CABG. In the on-pump cohort, there was no significant association between procedure order and the outcomes (all p>0.05). In the off-pump cohort, non-first procedures were associated with an increased number of AEC (adjusted rate ratio 1.29, 95% CI 1.13 to 1.47, p<0.001), myocardial infarction (adjusted OR (ORadj) 1.43, 95% CI 1.13 to 1.81, p=0.003) and stroke (ORadj 1.73, 95% CI 1.18 to 2.53, p=0.005) compared with first procedures. These increases were only found to be statistically significant when the procedure was performed by surgeons with <20 years' practice or surgeons with a preindex volume <700 cases.CONCLUSIONS:For a technically challenging surgical procedure like off-pump CABG, prior workload adversely affected patient outcomes.
BMJ quality & safety 2023
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 (i) a cross-sectional quantitative study to assess inter-team agreement on treatment strategy for retrospectively enrolled complex CAD patients and (ii) 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 four 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, and meeting process) and 10 subthemes. Recommendations of heart team implementation were generated based on qualitative and quantitative data at five 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.CONCLUSION: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.
European heart journal. Quality of care & clinical outcomes 2022
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.
BMJ open 2022
OBJECTIVE:In patients undergoing cardiac surgery, reduced preoperative ejection fraction (EF) and senior age are associated with a worse outcome. As most outcome data available for these patients are mainly from Western surgical populations involving specific surgery types, our aim is to evaluate the real-world characteristics and perioperative outcomes of surgery in senior-aged heart failure patients with reduced EF across a broad range cardiac surgeries.METHODS:Data were obtained from the China Heart Failure Surgery Registry (China-HFSR) database, a nationwide multicenter registry study in mainland China. Multiple variable regression analysis was performed in patients over 75 years old to identify risk factors associated with mortality.RESULTS:From 2012 to 2017, 578 senior-aged (> 75 years) patients were enrolled in China HFSR, 21.1% of whom were female. Isolated coronary bypass grafting (CABG) were performed in 71.6% of patients, 10.1% of patients underwent isolated valve surgery and 8.7% received CABG combined with valve surgery. In-hospital mortality was 10.6%, and the major complication rate was 17.3%. Multivariate analysis identified diabetes mellitus (odds ratio (OR) = 1.985), increased creatinine (OR = 1.007), New York Heart Association (NYHA) Class III (OR = 1.408), NYHA class IV (OR = 1.955), cardiogenic shock (OR, 6.271), and preoperative intra-aortic balloon pump insertion (OR = 3.426) as independent predictors of in-hospital mortality.CONCLUSIONS:In senior-aged patients, preoperative evaluation should be carefully performed, and strict management of reversible factors needs more attention. Senior-aged patients commonly have a more severe disease status combined with more frequent comorbidities, which may lead to a high risk in mortality.
Journal of geriatric cardiology : JGC 2021
BACKGROUND:China has witnessed a rapid increase in the volume of coronary artery bypass grafting (CABG) but substantial gaps in the performance for CABG across the nation. The present study aimed to investigate the change in CABG performance after years of quality improvement measures in a national registry in China.METHODS:The study included 66 971 patients who underwent isolated CABG in a cohort of 74 tertiary hospitals in China between January 2013 and December 2018. Data were collected from the Chinese Cardiac Surgery Registry. Outcomes were in-hospital mortality and postoperative length of stay. Five process measures for surgical technique and secondary prevention were also analyzed. We described the changes in the overall performance and interhospital heterogeneity across the years.RESULTS:The in-hospital mortality declined from 0.9% in 2013 to 0.6 in 2018, with a risk-adjusted odds ratio of 0.66 (95% CI, 0.46-0.93; P<0.001). The standard mean difference for risk-standardized mortality rate between hospitals in the lowest and highest quartile narrowed from 1.63 in 2013 to 1.35 in 2018. The median (interquartile range) hospital-level rate of using arterial graft increased from 93.9% (86.0%-97.8%) to 94.6% (83.3%-99.2%), but the difference was not statistically significant. Meanwhile, the rate of free from blood transfusion increased from 17.0% (2.6%-32.0%) to 34.1% (8.8%-52.9%). The hospital-level rate of prescribing β-blockers at discharge significantly increased from 82.8% (66.7%-90.3%) to 91.1% (82.1%-97.1%), statin from 75.8% (55.7%-88.9%) to 88.9% (75.0%-96.0%), and aspirin from 90.3% (83.9%-95.2%) to 95.3% (88.9%-98.1%).CONCLUSIONS:In the Chinese Cardiac Surgery Registry, there were notable improvements in the treatment process related to CABG and decline of in-hospital mortality with reduced interhospital heterogeneity.
Circulation. Cardiovascular quality and outcomes 2021
