High-Risk Committee for Cardiac Surgery Decision-Making: Results From 110 Consecutive Patients.
Journal
The Annals of thoracic surgery
ISSN: 1552-6259
Titre abrégé: Ann Thorac Surg
Pays: Netherlands
ID NLM: 15030100R
Informations de publication
Date de publication:
08 2021
08 2021
Historique:
received:
10
06
2020
revised:
24
08
2020
accepted:
11
09
2020
pubmed:
1
11
2020
medline:
7
9
2021
entrez:
31
10
2020
Statut:
ppublish
Résumé
This study evaluated our institutional experience in forming a surgeon-based committee to discuss and provide consensus opinion on high-risk cardiac surgical cases. The committee consisted of 4 surgeons with at least 1 senior surgeon at any given time with a rotating schedule. Patients with a Society of Thoracic Surgeons predicted risk of mortality above specified thresholds were mandated for referral to the committee in addition to patients referred at the discretion of the surgeon. Kaplan-Meier analysis was used to model survival. A total of 110 consecutive patients were reviewed by the committee. The most common procedure types for referral were isolated coronary artery bypass grafting (47.3%; n = 52) and coronary artery bypass grafting with concomitant aortic valve replacement (19.1%; n = 21). The overall median Society of Thoracic Surgeons predicted risk of mortality for referred patients was 5.35% (interquartile range, 4.07%-7.89%). After group discussion, a total of 62 patients were recommended to proceed with surgery (56.4%). Reasons for declining surgery included consensus that an intervention was not indicated (39.6%; n = 19), that an alternative, nonsurgical procedure was recommended (29.2%; n = 14), that there was continued medical management and reevaluation (18.8%; n = 9), and that the patient was deemed at too high a risk for surgery (12.5%; n = 6). Operative mortality in patients proceeding with surgery was 4.6% (n = 2), with an observed-to-expected mortality of 0.86. The 6-month survival after surgery was 92.2%. Implementation of a surgeon-based committee to discuss high-risk cases provided a unified voice to referring physicians and facilitated consensus decision-making with acceptable clinical outcomes in a challenging patient cohort.
Sections du résumé
BACKGROUND
This study evaluated our institutional experience in forming a surgeon-based committee to discuss and provide consensus opinion on high-risk cardiac surgical cases.
METHODS
The committee consisted of 4 surgeons with at least 1 senior surgeon at any given time with a rotating schedule. Patients with a Society of Thoracic Surgeons predicted risk of mortality above specified thresholds were mandated for referral to the committee in addition to patients referred at the discretion of the surgeon. Kaplan-Meier analysis was used to model survival.
RESULTS
A total of 110 consecutive patients were reviewed by the committee. The most common procedure types for referral were isolated coronary artery bypass grafting (47.3%; n = 52) and coronary artery bypass grafting with concomitant aortic valve replacement (19.1%; n = 21). The overall median Society of Thoracic Surgeons predicted risk of mortality for referred patients was 5.35% (interquartile range, 4.07%-7.89%). After group discussion, a total of 62 patients were recommended to proceed with surgery (56.4%). Reasons for declining surgery included consensus that an intervention was not indicated (39.6%; n = 19), that an alternative, nonsurgical procedure was recommended (29.2%; n = 14), that there was continued medical management and reevaluation (18.8%; n = 9), and that the patient was deemed at too high a risk for surgery (12.5%; n = 6). Operative mortality in patients proceeding with surgery was 4.6% (n = 2), with an observed-to-expected mortality of 0.86. The 6-month survival after surgery was 92.2%.
CONCLUSIONS
Implementation of a surgeon-based committee to discuss high-risk cases provided a unified voice to referring physicians and facilitated consensus decision-making with acceptable clinical outcomes in a challenging patient cohort.
Identifiants
pubmed: 33127404
pii: S0003-4975(20)31755-0
doi: 10.1016/j.athoracsur.2020.09.014
pmc: PMC9057451
mid: NIHMS1797060
pii:
doi:
Types de publication
Journal Article
Multicenter Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
582-588Subventions
Organisme : NHLBI NIH HHS
ID : T32 HL098036
Pays : United States
Informations de copyright
Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Références
J Thorac Cardiovasc Surg. 2015 Nov;150(5):1061-7, 1068.e1-3
pubmed: 26384752
Ann Thorac Surg. 2018 May;105(5):1419-1428
pubmed: 29577924
Eur Heart J. 2017 Sep 21;38(36):2739-2791
pubmed: 28886619
Curr Opin Cardiol. 2017 Sep;32(5):627-632
pubmed: 28797011
J Am Coll Cardiol. 2017 Aug 8;70(6):689-700
pubmed: 28693934
Curr Treat Options Cardiovasc Med. 2019 Feb 9;21(1):5
pubmed: 30739215
J Am Coll Cardiol. 2013 Mar 5;61(9):903-7
pubmed: 23449424
Bull N Y Acad Med. 1992 Mar-Apr;68(2):297-302
pubmed: 1586864
J Am Coll Cardiol. 2017 Jul 11;70(2):252-289
pubmed: 28315732
N Engl J Med. 2020 Feb 20;382(8):778-779
pubmed: 32074429
JAMA Surg. 2018 Oct 1;153(10):955-956
pubmed: 29617534
Ann Thorac Surg. 2018 May;105(5):1411-1418
pubmed: 29577925
J Am Coll Cardiol. 2014 Nov 4;64(18):1929-49
pubmed: 25077860