157 results on '"Derrick Y. Tam"'
Search Results
2. Commentary: Invasive therapy for hypertrophic obstructive cardiomyopathy: Is it time to reexamine the guidelines?
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Stephen E. Fremes, Amine Mazine, and Derrick Y. Tam
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,medicine ,MEDLINE ,Surgery ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business ,Obstructive cardiomyopathy - Published
- 2022
3. Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada
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Louise Y. Sun, Vicki Alexopoulos, Anna Chu, Derrick Y. Tam, Christopher M Feindel, Peter C. Austin, Maral Ouzounian, Natasa Tusevljak, Garth H Oakes, Douglas S. Lee, Xuesong Wang, and Jiming Fang
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Adult ,Male ,medicine.medical_specialty ,Bypass grafting ,Logistic regression ,Aortic valve replacement ,Predictive Value of Tests ,Internal medicine ,Humans ,Medicine ,Registries ,Derivation ,Coronary Artery Bypass ,Aged ,Retrospective Studies ,Heart Valve Prosthesis Implantation ,Ontario ,business.industry ,Research ,Mortality rate ,General Medicine ,Perioperative ,Middle Aged ,Health Services ,medicine.disease ,surgical procedures, operative ,30 day mortality ,Aortic Valve ,Cardiology ,Female ,business ,Ontario canada - Abstract
Background Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR. Methods We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020). Results The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts. Interpretation Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.
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- 2021
4. Commentary: Artificial intelligence to predict mortality: The rise of the machines?
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Derrick Y. Tam, Dion Chung, and Stephen E. Fremes
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Pulmonary and Respiratory Medicine ,business.industry ,Medicine ,Surgery ,Artificial intelligence ,Cardiology and Cardiovascular Medicine ,business - Published
- 2022
5. Commentary: When less is not more—volume-outcome relationships in aortic valve replacement
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Dinela Rushani, Stephen E. Fremes, and Derrick Y. Tam
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Heart Valve Prosthesis Implantation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Volume outcome ,MEDLINE ,Aortic Valve Stenosis ,medicine.disease ,Surgery ,Transcatheter Aortic Valve Replacement ,Treatment Outcome ,Aortic valve replacement ,Aortic Valve ,Heart Valve Prosthesis ,Humans ,Medicine ,Cardiology and Cardiovascular Medicine ,business - Published
- 2022
6. Commentary: Should valve-in-valve transcatheter aortic valve replacement be first-line treatment for failed aortic bioprostheses?
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Derrick Y. Tam, Jimmy J H Kang, and Stephen E. Fremes
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Bioprosthesis ,Heart Valve Prosthesis Implantation ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Transcatheter aortic ,business.industry ,medicine.medical_treatment ,Aortic Valve Stenosis ,Prosthesis Design ,Valve in valve ,Prosthesis Failure ,Surgery ,Transcatheter Aortic Valve Replacement ,First line treatment ,Treatment Outcome ,Valve replacement ,Aortic Valve ,Heart Valve Prosthesis ,medicine ,Humans ,Cardiology and Cardiovascular Medicine ,business - Published
- 2022
7. The Impact of the COVID-19 Pandemic on Cardiac Procedure Wait List Mortality in Ontario, Canada
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Stephen E. Fremes, David Naimark, Derrick Y. Tam, Beate Sander, Louise Y. Sun, Sandra Lauck, Maral Ouzounian, Feng Qiu, Dennis T. Ko, Ragavie Manoragavan, Harindra C. Wijeysundera, and Ansar Hassan
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medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,Referral ,business.industry ,Proportional hazards model ,medicine.medical_treatment ,Hazard ratio ,Percutaneous coronary intervention ,Confidence interval ,Emergency medicine ,Pandemic ,Health care ,Medicine ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background The novel SARS-CoV-2 (COVID-19) pandemic has dramatically altered the delivery of healthcare services, resulting in significant referral pattern changes, delayed presentations, and procedural delays. Our objective was to determine the effect of the COVID-19 pandemic on all-cause mortality in patients awaiting commonly performed cardiac procedures. Methods Clinical and administrative data sets were linked to identify all adults referred for: (1) percutaneous coronary intervention; (2) coronary artery bypass grafting; (3) valve surgery; and (4) transcatheter aortic valve implantation, from January 2014 to September 2020 in Ontario, Canada. Piece-wise regression models were used to determine the effect of the COVID-19 pandemic on referrals and procedural volume. Multivariable Cox proportional hazards models were used to determine the effect of the pandemic on waitlist mortality for the 4 procedures. Results We included 584,341 patients who were first-time referrals for 1 of the 4 procedures, of whom 37,718 (6.4%) were referred during the pandemic. The pandemic period was associated with a significant decline in the number of referrals and procedures completed compared with the prepandemic period. Referral during the pandemic period was a significant predictor for increased all-cause mortality for the percutaneous coronary intervention (hazard ratio, 1.83; 95% confidence interval, 1.47-2.27) and coronary artery bypass grafting (hazard ratio, 1.96; 95% confidence interval, 1.28-3.01), but not for surgical valve or transcatheter aortic valve implantation referrals. Procedural wait times were shorter during the pandemic period compared with the prepandemic period. Conclusions There was a significant decrease in referrals and procedures completed for cardiac procedures during the pandemic period. Referral during the pandemic was associated with increased all-cause mortality while awaiting coronary revascularization.
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- 2021
8. Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist
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Derrick Y. Tam, Mamas A. Mamas, Harindra C. Wijeysundera, Anan Bader Eddeen, Louise Y. Sun, and Thierry G. Mesana
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Male ,medicine.medical_specialty ,Waiting Lists ,Myocardial Infarction ,Risk Assessment ,Cohort Studies ,Health care ,medicine ,Humans ,Endocarditis ,Angina, Unstable ,Derivation ,Myocardial infarction ,Cardiac Surgical Procedures ,Aged ,Proportional Hazards Models ,Retrospective Studies ,Heart Failure ,Ontario ,Models, Statistical ,Unstable angina ,Proportional hazards model ,business.industry ,Research ,General Medicine ,Health Services ,Middle Aged ,medicine.disease ,Cardiac surgery ,Hospitalization ,Cardiovascular Diseases ,Heart failure ,Emergency medicine ,Female ,business - Abstract
Background: Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery. Methods: We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection. Results: Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points. Interpretation: We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.
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- 2021
9. Reply: Relating the indexed effective orifice area and mean transprosthesis gradient to define patient-prosthesis mismatch: Are we sure a relationship exists?
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Stephen E. Fremes, Derrick Y. Tam, and Abdullah Malik
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Orthodontics ,Effective orifice area ,business.industry ,medicine.medical_treatment ,Medicine ,business ,Prosthesis - Published
- 2022
10. Real-World Health-Economic Considerations Around Aortic-Valve Replacement in a Publicly Funded Health System
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Harindra C. Wijeysundera, Derrick Y. Tam, Malak Elbatarny, and Rafael Neves Miranda
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Canada ,Public Health Systems Research ,medicine.medical_treatment ,Funding Mechanism ,030204 cardiovascular system & hematology ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Aortic valve replacement ,Willingness to pay ,Outcome Assessment, Health Care ,Health care ,medicine ,Humans ,030212 general & internal medicine ,Distributive justice ,Heart Valve Prosthesis Implantation ,Actuarial science ,business.industry ,Ross procedure ,Health technology ,Aortic Valve Stenosis ,Bioethics ,medicine.disease ,Aortic Valve ,Heart Valve Prosthesis ,Risk Adjustment ,Cardiology and Cardiovascular Medicine ,business ,Decision Making, Shared - Abstract
Herein, we describe the unique interplay among biomedical ethics, principles of distributive justice, and economic theory to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian health care system, transcatheter aortic-valve implantation is associated with higher costs but also higher incremental health benefits compared with surgical aortic-valve replacement. At current willingness to pay thresholds, transcatheter aortic-valve replacement is likely cost effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight the nuances within each subgroup of surgical risk that merit careful consideration by the heart team. Moreover, incorporation of patients and their preferences in decision-making is key. In particular, in young, low-risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, selection of valve prosthesis, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that, universally, patients prefer a less invasive approach compared with a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues.
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- 2021
11. Commentary: Rapid Deployment Does Not Necessarily Warrant Rapid Adoption
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Dustin Tanaka, Derrick Y. Tam, and Stephen E. Fremes
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Pulmonary and Respiratory Medicine ,Warrant ,business.industry ,Software deployment ,Medicine ,Surgery ,General Medicine ,Cardiology and Cardiovascular Medicine ,business ,Data science - Published
- 2022
12. Cardiac Rehabilitation Is Associated With Improved Long-Term Outcomes After Coronary Artery Bypass Grafting
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Paul Oh, Harindra C. Wijeysundera, Bing Yu, Reena Karkhanis, Derrick Y. Tam, Stephen E. Fremes, David A. Alter, and Alex Kiss
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lcsh:Diseases of the circulatory (Cardiovascular) system ,medicine.medical_specialty ,Rehabilitation ,Referral ,business.industry ,medicine.medical_treatment ,Hazard ratio ,medicine.disease ,Confidence interval ,Coronary artery disease ,lcsh:RC666-701 ,Internal medicine ,Cohort ,medicine ,Original Article ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business ,Stroke - Abstract
Background: Although cardiac rehabilitation (CR) has proven to have short- and mid-term benefit in treatment of coronary artery disease, its long-term benefit in patients who have undergone coronary artery bypass grafting (CABG) is less certain. Our objective was to examine the late outcomes of patients who attended CR within the first year after CABG. Methods: Adult CABG patients referred to Toronto Rehabilitation Institute (CR group: were referred and attended at least 1 session; No-CR group: were referred but did not attend) between January 1996 and September 2008 were identified through linkages with clinical and provincial administrative databases for comorbidities and outcome ascertainment. The primary outcome was a composite of all-cause mortality, acute myocardial infarction, stroke or repeat revascularization (major adverse cardiac and cerebrovascular events [MACCE]). The secondary outcome was all-cause mortality. Multivariable Cox proportional hazard models were used to assess the CR treatment effect, adjusting for baseline characteristics. Results: The study cohort consisted of 5,000 patients—3,685 (73.7%) in the CR group and 1,315 (26.3%) in the No-CR group. Median referral time was 32.5 days, and follow-up was 13.1 years. The CR group patients, compared with the No-CR group, were younger (age 62.6 ± 9.6 vs 64.0 ± 10.5 years), were more likely to be male (85.0% vs 79.5%), and had fewer cardiac comorbidities. In adjusted analyses, the CR group was associated with decreased MACCE (hazard ratio 0.83, 95% confidence interval 0.75-0.91, P < 0.0001) and a higher adjusted survival at 15 years (66.3% vs 60.1%, hazard ratio 0.76, 95% confidence interval 0.68-0.84, P < 0.0001), as compared with the No-CR group. Conclusions: There was a reduction in MACCE and late mortality associated with CR attendance, highlighting the importance of patient referral and participation in CR after CABG. Résumé: Contexte: La réadaptation cardiaque (RC) s’est révélée bénéfique à court et à moyen terme dans le traitement des coronaropathies, mais on en sait moins sur ses bienfaits à long terme chez les patients ayant subi un pontage aortocoronarien (PAC). Nous avons donc examiné les issues à long terme chez des patients ayant participé à un programme de RC dans l’année suivant un PAC. Méthodologie: À partir des données couplées des bases de données des cliniques et de l’administration provinciale, nous avons relevé tous les patients adultes ayant subi un PAC qui ont été orientés vers l’Institut de réadaptation de Toronto (groupe RC : patients orientés vers le programme et ayant participé à au moins 1 séance; groupe sans RC : patients orientés vers le programme, mais n’ayant participé à aucune séance) entre janvier 1996 et septembre 2008, afin d’établir les affections concomitantes et les résultats obtenus. Le critère d’évaluation principal composé comprenait la mortalité toutes causes confondues, l’infarctus du myocarde aigu, l’accident vasculaire cérébral (AVC) ou une nouvelle revascularisation en raison d’un événement cardiaque ou cérébrovasculaire majeur (ECCVM). Le critère d’évaluation secondaire était la mortalité toutes causes confondues. Nous avons utilisé des modèles à risques proportionnels de Cox multivariés pour évaluer l’effet thérapeutique de la RC, en apportant les corrections nécessaires pour tenir compte des caractéristiques initiales des patients. Résultats: La cohorte de l’étude réunissait 5 000 patients – 3 685 (73,7 %) dans le groupe RC et 1 315 (26,3 %) dans le groupe sans RC. Les valeurs médianes du temps écoulé avant l’orientation vers un programme de RC et de la période du suivi étaient de 32,5 jours et de 13,1 ans, respectivement. Comparativement aux patients du groupe sans RC, les patients du groupe RC étaient plus jeunes (62,6 ± 9,6 ans vs 64,0 ± 10,5 ans), étaient dans une plus forte proportion des hommes (85,0 % vs 79,5 %) et présentaient un moins grand nombre d’affections cardiaques concomitantes. À l’issue des analyses après corrections, on a observé dans le groupe RC une réduction du taux d’ECCVM (rapport des risques instantanés de 0,83; intervalle de confiance [IC] à 95 %, de 0,75 à 0,91; p < 0,0001) et une augmentation du taux de survie à 15 ans corrigé (66,3 % vs 60,1 %; rapport des risques instantanés de 0,76; IC à 95 %, de 0,68 à 0,84; p < 0,0001), comparativement au groupe sans RC. Conclusions: La participation à un programme de RC a été associée à une diminution du risque d’ECCVM et de mortalité tardive, ce qui fait ressortir l’importance d’orienter les patients ayant subi un PAC vers de tels programmes et de les encourager à y participer.
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- 2021
13. Decision analysis and personalized clinical tool for cerebrospinal fluid drains in thoracoabdominal aortic aneurysms repair
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Irbaz Hameed, Lisa Q. Rong, Faiza M. Khan, Mario Gaudino, N. Bryce Robinson, Stephen E. Fremes, Leonard N. Girardi, and Derrick Y. Tam
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Subarachnoid hemorrhage ,030204 cardiovascular system & hematology ,Thoracoabdominal Aortic Aneurysms ,Decision Support Techniques ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Epidural hematoma ,Cerebrospinal fluid ,Risk Factors ,medicine ,Humans ,Retrospective Studies ,Aortic Aneurysm, Thoracic ,Spinal Cord Ischemia ,business.industry ,Spinal cord ischemia ,Odds ratio ,medicine.disease ,Surgery ,Treatment Outcome ,030228 respiratory system ,Drainage ,Cardiology and Cardiovascular Medicine ,business ,Meningitis ,Decision analysis - Abstract
BACKGROUND AND AIM The routine use of cerebrospinal fluid (CSF) drainage in patients undergoing operative repair of thoracoabdominal aneurysms (TAAA) has been associated with decreased rates of spinal cord ischemia. The use of CSF drains is not without consequence, however with complications including subarachnoid hemorrhage, epidural hematoma, meningitis, and, in 1% of cases, death. To date, a decision analysis tool to help clinicians decide when to use and not to use a CSF drain does not exist. In this analysis, we set out to develop a decision analysis tool for CSF drain placement in patients undergoing operative repair of TAAA. METHODS A Markov state-transition cohort model that compared TAAA repair with adjunctive CSF drain insertion to TAAA repair without drain insertion for the outcome of life expectancy was developed in TreeAge 2020. The cycle length was 1 month and the time horizon was 60 months. RESULTS The use of a CSF drain was associated with improved 5-year life expectancy (3.21 ± 0.10 vs. 3.09 ± 0.11 life-years gained). In the sensitivity analysis that varied the effectiveness of a CSF drain (odds ratio closer to 1 = less effective), the use of a CSF drain resulted in higher life expectancy in almost all scenarios. CONCLUSIONS The routine use of a CSF drain in patients undergoing TAAA repair is safe and effective, with few exceptions. This decision analysis tool can be used by clinicians to develop a personalized approach.
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- 2020
14. Commentary: Do we always need to look at the coronaries in infective endocarditis?
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Derrick Y. Tam, Malak Elbatarny, and Stephen E. Fremes
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Infective endocarditis ,medicine ,MEDLINE ,Surgery ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,medicine.disease ,business - Published
- 2022
15. Commentary: The problem of valve prosthesis–patient mismatch revisited
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Joanna Chikwe and Derrick Y. Tam
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Valve prosthesis ,medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2022
16. A Real-World Examination of Embolic Protection Devices for Transcatheter Aortic Valve Replacement
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Derrick Y. Tam and Harindra C. Wijeysundera
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medicine.medical_specialty ,Transcatheter aortic ,Valve replacement ,business.industry ,Physiology (medical) ,medicine.medical_treatment ,medicine ,Embolic Protection Devices ,Cardiology and Cardiovascular Medicine ,business ,Surgery - Published
- 2021
17. Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease
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Louise Y. Sun, Douglas S. Lee, Peter C. Austin, Christoffer Dharma, Husam Abdel-Qadir, Rodolfo V. Rocha, Harindra C. Wijeysundera, Mario Gaudino, Jacob A. Udell, Stephen E. Fremes, Michael E. Farkouh, and Derrick Y. Tam
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Revascularization ,Coronary artery disease ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Internal medicine ,Diabetes Mellitus ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Myocardial infarction ,Coronary Artery Bypass ,Aged ,Retrospective Studies ,Ontario ,Proportional hazards model ,business.industry ,Hazard ratio ,Percutaneous coronary intervention ,medicine.disease ,Survival Rate ,Treatment Outcome ,surgical procedures, operative ,Conventional PCI ,Propensity score matching ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background There remains a paucity of real-world observational evidence comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with diabetes and multivessel coronary artery disease (CAD). Objectives This study compared early and long-term outcomes of PCI versus CABG in patients with diabetes. Methods Clinical and administrative databases in Ontario, Canada were linked to obtain records of all patients with diabetes with angiographic evidence of 2- or 3-vessel CAD who were treated with either PCI or isolated CABG from 2008 to 2017. A 1:1 propensity score match was performed to account for baseline differences. All-cause mortality and the composite of myocardial infarction, repeat revascularization, stroke, or death (termed major cardiovascular and cerebrovascular events [MACCEs]) were compared between the matched groups using a stratified log-rank test and Cox proportional hazards model. Results A total of 4,519 and 9,716 patients underwent PCI and CABG, respectively. Before matching, patients who underwent CABG were significantly younger (age 65.7 years vs. 68.3 years), were more likely to be men (78% vs. 73%) and had more severe CAD. Propensity score matching based on 23 baseline covariates yielded 4,301 well-balanced pairs. There was no difference in early mortality between PCI and CABG (2.4% vs. 2.3%; p = 0.721) after matching. The median and maximum follow-ups were 5.5 and 11.5 years, respectively. All-cause mortality (hazard ratio [HR]: 1.39; 95% CI: 1.28 to 1.51) and overall MACCEs (HR: 1.99; 95% CI: 1.86 to 2.12) were significantly higher with PCI compared with CABG. Conclusions In patients with multivessel CAD and diabetes, CABG was associated with improved long-term mortality and freedom from MACCEs compared with PCI.
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- 2020
18. The Use of Decision Modelling to Inform Timely Policy Decisions on Cardiac Resource Capacity During the COVID-19 Pandemic
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Mirna Rahal, Madhu K. Natarajan, Kali Barrett, Harindra C. Wijeysundera, Graham Woodward, Raphael Ximenes, Yasin A. Khan, Garth H. Oakes, Stephen Mac, Derrick Y. Tam, Beate Sander, and David M.J. Naimark
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medicine.medical_specialty ,Waiting Lists ,Pneumonia, Viral ,Worst-case scenario ,030204 cardiovascular system & hematology ,Article ,Decision Support Techniques ,Coronary artery disease ,Health care rationing ,Betacoronavirus ,03 medical and health sciences ,0302 clinical medicine ,Resource (project management) ,Ambulatory care ,Acute care ,Intensive care ,Epidemiology ,Ambulatory Care ,Humans ,Medicine ,030212 general & internal medicine ,Policy Making ,Intensive care medicine ,Pandemics ,Ontario ,Health Care Rationing ,SARS-CoV-2 ,business.industry ,COVID-19 ,medicine.disease ,Organizational Innovation ,3. Good health ,Cardiovascular Diseases ,Cardiology Service, Hospital ,Coronavirus Infections ,Cardiology and Cardiovascular Medicine ,business - Abstract
Unstructured Abstract (250 words) In Ontario, on March 16th, 2020, a directive was issued to all acute care hospitals to halt non-essential procedures in anticipation for a potential surge in COVID-19 patients. This included scheduled outpatient cardiac surgical and interventional procedures that required the use of intensive care units, ventilators, and skilled critical care personnel, given that these procedures would draw from the same pool of resources required for critically ill COVID-19 patients. We adapted the COVID-19 Resource Estimator (CORE) decision analytic model by adding a cardiac component to determine the impact of various policy decisions on the incremental waitlist growth and estimated waitlist mortality for three key groups of cardiovascular disease patients; coronary artery disease, valvular heart disease, and arrhythmias. We provided predictions based on COVID-19 epidemiology available in real-time, in 3 phases. First, in the initial crisis phase, in a worst case scenario, we showed that the potential number of waitlist related cardiac deaths would be orders of magnitude less than those who would die of COVID-19 if critical cardiac care resources were diverted to the care of COVID-19 patients. Second, with better local epidemiology data, we predicted that across five regions of Ontario, there may be insufficient resources to resume all elective outpatient cardiac procedures. Finally in the recovery phase, we showed that the estimated incremental growth in waitlist for all cardiac procedures is likely substantial. These outputs informed timely, data-driven decisions during the COVID-19 pandemic regarding the provision of cardiovascular care., In Ontario, on March 16th, 2020, a directive was issued to all acute care hospitals to halt non-essential procedures in anticipation for a potential COVID-19 patient surge. This manuscript provides examples of how decision analytic models have helped informed policy decisions and to assess the impact of these policies on incremental waitlist activity for cardiac procedures during the COVID-19 pandemic.
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- 2020
19. Predictors of Cumulative Health Care Costs Associated With Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis
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Derrick Y. Tam, Stephen E. Fremes, Harindra C. Wijeysundera, Kayley A. Henning, Gabby Elbaz-Greener, Feng Qiu, Sandra Lauck, John G. Webb, and Karin H. Humphries
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Male ,medicine.medical_specialty ,Referral ,Total cost ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Risk Assessment ,Severity of Illness Index ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,0302 clinical medicine ,Valve replacement ,Risk Factors ,Interquartile range ,Severity of illness ,medicine ,Humans ,Registries ,030212 general & internal medicine ,health care economics and organizations ,Dialysis ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Retrospective cohort study ,Aortic Valve Stenosis ,Health Care Costs ,3. Good health ,Hospitalization ,Cost driver ,Aortic Valve ,Emergency medicine ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Background There is wide variation in hospitalization costs for transcatheter aortic valve replacement (TAVR), suggesting inefficiency in care delivery. Our goal was to identify drivers of healthcare costs in TAVR. Methods Demographics, procedural details, in-hospital complications, and costs for all adults undergoing first-time TAVR from 2012-2016 in Ontario, Canada, were obtained through linkages of clinical/administrative databases. Total costs included were from initial referral to the first of either death or 1-year post-TAVR. Phase-based costing was performed to empirically estimate the presence, duration and cost/patient for each phase up to 1-year or death. Multivariable regression was used to identify drivers of cost accumulation per phase. Results We identified 2,009 first-time TAVR patients (mean age 81.7±7.6, 45.9% female and STS-score of 7.2±5.8). Phases of cost were identified with an early high cost period within 60-days of referral, a second phase from the procedure to 60-days, and a stable phase from 60-360 days post-procedure. The referral phase median cost was $4,527 (Interquartile range [IQR]: 1,708-12,594), the procedure to 60-days phase median cost was $29,518 (IQR: 24,842-40,279) and the post 60-day stable phase median cost was $6,053 (IQR: 3,320-17,048). Predictors of higher cost in the referral phase were in-hospital wait-location, dialysis dependence, and heart failure status. In the second (procedural) phase, predictors were non-transfemoral access, complications of stroke and pacemaker insertion. Predictors of higher cost in the third (stable) phase were predominantly non-modifiable, such as frailty. Conclusions This analysis shows that there are 3 distinct phases of cost accumulation from referral to post-TAVR with some potentially modifiable cost drivers in each phase.
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- 2020
20. Impact of Transcatheter Aortic Valve Durability on Life Expectancy in Low-Risk Patients With Severe Aortic Stenosis
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Derrick Y. Tam, Harindra C. Wijeysundera, David Cohen, John G. Webb, Mario Gaudino, David Naimark, and Stephen E. Fremes
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Male ,Reoperation ,medicine.medical_specialty ,Transcatheter aortic ,medicine.medical_treatment ,Comorbidity ,Transcatheter Aortic Valve Replacement ,Life Expectancy ,Valve replacement ,Aortic valve replacement ,Risk Factors ,Physiology (medical) ,Internal medicine ,medicine ,Humans ,Aged ,Aged, 80 and over ,business.industry ,Aortic Valve Stenosis ,Prognosis ,medicine.disease ,Prosthesis Failure ,Clinical trial ,Stenosis ,Treatment Outcome ,Cardiology ,Life expectancy ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background: Recent clinical trial results showed that transcatheter aortic valve replacement (TAVR) is noninferior and may be superior to surgical aortic valve replacement (SAVR) for mortality, stroke, and rehospitalization. However, the impact of transcatheter valve durability remains uncertain. Methods: Discrete event simulation was used to model hypothetical scenarios of TAVR versus SAVR durability in which TAVR failure times were varied to determine the impact of TAVR valve durability on life expectancy in a cohort of low-risk patients similar to those in recent trials. Discrete event simulation modeling was used to estimate the tradeoff between a less invasive procedure with unknown valve durability (TAVR) and that of a more invasive procedure with known durability (SAVR). Standardized differences were calculated, and a difference >0.10 was considered clinically significant. In the base-case analysis, patients with structural valve deterioration requiring reoperation were assumed to undergo a valve-in-valve TAVR procedure. A sensitivity analysis was conducted to determine the impact of TAVR valve durability on life expectancy in younger age groups (40, 50, and 60 years). Results: Our cohort consisted of patients with aortic stenosis at low surgical risk with a mean age of 73.4±5.9 years. In the base-case scenario, the standardized difference in life expectancy was Conclusions: According to our simulation models, the durability of TAVR valves must be 70% shorter than that of surgical valves to result in reduced life expectancy in patients with demographics similar to those of recent trials. However, in younger patients, this threshold for TAVR valve durability was substantially higher. These findings suggest that durability concerns should not influence the initial treatment decision concerning TAVR versus SAVR in older low-risk patients on the basis of current evidence supporting TAVR valve durability. However, in younger low-risk patients, valve durability must be weighed against other patient factors such as life expectancy.
- Published
- 2020
21. Variability in opioid prescribing practices among cardiac surgeons and trainees
- Author
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Marc P. Pelletier, Ali Fatehi Hassanabad, Sameer A. Hirji, Ryan Buyting, Philippe Tremblay, Sabin J. Bozso, Edward Percy, Spencer Kiehm, Claudia L. Cote, Ming Hao Guo, Richard C. Cook, Alexandra Malarczyk, Tsuyoshi Kaneko, Charles Laurin, Logan Atkinson, Derrick Y. Tam, Iqbal H. Jaffer, Jean-Francois Légaré, Carly Lodewyks, and Morgan Harloff
- Subjects
Male ,Pulmonary and Respiratory Medicine ,Canada ,medicine.medical_specialty ,Substance-Related Disorders ,Analgesic ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Interquartile range ,Surveys and Questionnaires ,medicine ,Humans ,Pain Management ,Cardiac Surgical Procedures ,Practice Patterns, Physicians' ,Medical prescription ,Surgeons ,Pain, Postoperative ,business.industry ,Public health ,Opioid use disorder ,Training Support ,Opioid-Related Disorders ,medicine.disease ,Patient Discharge ,Cardiac surgery ,Analgesics, Opioid ,Prescriptions ,030228 respiratory system ,Opioid ,Family medicine ,Pill ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Background and aim The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. Methods A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. Results Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. Conclusions Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.
- Published
- 2020
22. The cost-effectiveness of transcatheter aortic valve replacement in low surgical risk patients with severe aortic stenosis
- Author
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Joanna Chikwe, Harindra C. Wijeysundera, Paymon M. Azizi, Derrick Y. Tam, Mario Gaudino, and Stephen E. Fremes
- Subjects
medicine.medical_specialty ,Transcatheter aortic ,Cost effectiveness ,Cost-Benefit Analysis ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Severity of Illness Index ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,0302 clinical medicine ,Valve replacement ,Aortic valve replacement ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Stroke ,Heart Valve Prosthesis Implantation ,business.industry ,Health Policy ,Aortic Valve Stenosis ,medicine.disease ,Surgical risk ,Stenosis ,Aortic valve stenosis ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Aims The economic value of transcatheter aortic valve replacement (TAVR) in low surgical risk patients with severe, symptomatic aortic stenosis is not known. Our objective was to determine the cost-effectiveness of balloon-expandable TAVR and self-expandable TAVR relative to surgical aortic valve replacement (SAVR) in low-risk patients. Methods and results A fully probabilistic Markov cohort model was constructed to estimate differences in costs and effectiveness [quality-adjusted life years (QALYs)] over the patient’s life-time time from the third-party payer’s perspective. Clinical outcomes modelled were alive/well (no complications), permanent stroke, ≥moderate paravalvular leak, new pacemaker, rehospitalization, and death. A network meta-analysis of the PARTNER 3 and Evolut Low Risk trial was performed to compare balloon-expandable TAVR, self-expandable TAVR, and SAVR for the efficacy inputs. Incremental-cost effectiveness ratios (ICER) were calculated. The total life-time costs in the balloon-expandable TAVR, self-expandable-TAVR, and SAVR arms were $37 330 ± 4724, $39 660 ± 4862, and $34 583 ± 6731, respectively, and total life-time QALYs gained were 9.15 ± 3.23, 9.13 ± 3.23, and 9.05 ± 3.20, respectively. The ICERs for balloon-expandable TAVR and self-expandable TAVR against SAVR were $27 196/QALY and $59 641/QALY, respectively. Balloon-expandable TAVR was less costly and more effective than self-expandable TAVR. There was substantial uncertainty, with 53% and 58% of model iterations showing balloon-expandable TAVR to be the preferred option at willingness-to-pay thresholds of $50 000/QALY and $100 000/QALY, respectively. Conclusion Compared with SAVR, TAVR, particularly with balloon-expandable prostheses may be a cost-effective option for patients with severe aortic stenosis at low surgical risk.
- Published
- 2020
23. Valve-Sparing Root Replacement Versus Composite Valve Grafting in Aortic Root Dilation: A Meta-Analysis
- Author
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Jehangir J. Appoo, Ismail El-Hamamsy, Derrick Y. Tam, Maral Ouzounian, Rodolfo V. Rocha, Mark D. Peterson, Bobby Yanagawa, Malak Elbatarny, Jan O. Friedrich, J. James Edelman, Michael W.A. Chu, and Munir Boodhwani
- Subjects
Pulmonary and Respiratory Medicine ,Aortic valve ,medicine.medical_specialty ,Aortic Diseases ,030204 cardiovascular system & hematology ,Rate ratio ,03 medical and health sciences ,0302 clinical medicine ,Bicuspid aortic valve ,Humans ,Medicine ,Myocardial infarction ,Stroke ,Heart Valve Prosthesis Implantation ,integumentary system ,business.industry ,medicine.disease ,Confidence interval ,Surgery ,Dissection ,medicine.anatomical_structure ,030228 respiratory system ,Relative risk ,Cardiology and Cardiovascular Medicine ,business - Abstract
Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts.We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded.A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P.01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P.01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P .01) risks were lower after valve sparing. Procedure type did not affect late reintervention.Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.
- Published
- 2020
24. An assessment of the quality of current clinical meta-analyses
- Author
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Leonard N. Girardi, Becky Baltich Nelson, Antonio P. DeRosa, Keith Mages, Diana Delgado, Mohamed Rahouma, Irbaz Hameed, Michelle Demetres, Kevin J. Pain, Mario Gaudino, Faiza M. Khan, Stephen E. Fremes, Derrick Y. Tam, and Drew Wright
- Subjects
Research Report ,medicine.medical_specialty ,PRESS ,Epidemiology ,media_common.quotation_subject ,education ,MEDLINE ,Health Informatics ,PRISMA ,Institute of medicine ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Clinical ,0302 clinical medicine ,Meta-Analysis as Topic ,medicine ,Humans ,Quality (business) ,030212 general & internal medicine ,IOM ,Methodological quality ,media_common ,lcsh:R5-920 ,business.industry ,Methodology ,Quality ,Meta-analysis ,Systematic review ,Cochrane ,Family medicine ,Scale (social sciences) ,Multivariate Analysis ,business ,lcsh:Medicine (General) ,Research Article - Abstract
Background The objective of this study was to assess the overall quality of study-level meta-analyses in high-ranking journals using commonly employed guidelines and standards for systematic reviews and meta-analyses. Methods 100 randomly selected study-level meta-analyses published in ten highest-ranking clinical journals in 2016–2017 were evaluated by medical librarians against 4 assessments using a scale of 0–100: the Peer Review of Electronic Search Strategies (PRESS), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Institute of Medicine’s (IOM) Standards for Systematic Reviews, and quality items from the Cochrane Handbook. Multiple regression was performed to assess meta-analyses characteristics’ associated with quality scores. Results The overall median (interquartile range) scores were: PRESS 62.5(45.8–75.0), PRISMA 92.6(88.9–96.3), IOM 81.3(76.6–85.9), and Cochrane 66.7(50.0–83.3). Involvement of librarians was associated with higher PRESS and IOM scores on multiple regression. Compliance with journal guidelines was associated with higher PRISMA and IOM scores. Conclusion This study raises concerns regarding the reporting and methodological quality of published MAs in high impact journals Early involvement of information specialists, stipulation of detailed author guidelines, and strict adherence to them may improve quality of published meta-analyses.
- Published
- 2020
25. Randomized Trials in Cardiac Surgery
- Author
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Alan J. Moskowitz, Andre Lamy, Antonino Di Franco, Marco A. Zenati, Annetine C. Gelijns, A. Laurie Shroyer, David P. Taggart, Mary E. Charlson, Frederick L. Grover, Mario Gaudino, Deepak L. Bhatt, Stephen E. Fremes, Andreas Boening, Stuart J. Head, Marcus Flather, Derrick Y. Tam, Wilko Reents, Peter Jüni, A. Pieter Kappetein, Marissa A. Miller, and Emilia Bagiella
- Subjects
medicine.medical_specialty ,Blinding ,business.industry ,Successful completion ,Clinical epidemiology ,030204 cardiovascular system & hematology ,Complex interventions ,3. Good health ,Cardiac surgery ,law.invention ,Design phase ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business ,Intensive care medicine - Abstract
Compared with randomized controlled trials (RCTs) in medical specialties, RCTs in cardiac surgery face specific issues. Individual and collective equipoise, rapid evolution of the surgical techniques, as well as difficulties in obtaining funding, and limited education in clinical epidemiology in the surgical community are among the most important challenges in the design phase of the trial. Use of complex interventions and learning curve effect, differences in individual operators' expertise, difficulties in blinding, and slow recruitment make the successful completion of cardiac surgery RCTs particularly challenging. In fact, over the course of the last 20 years, the number of cardiac surgery RCTs has declined significantly. In this review, a team of surgeons, trialists, and epidemiologists discusses the most important challenges faced by RCTs in cardiac surgery and provides a list of suggestions for the successful design and completion of cardiac surgery RCTs.
- Published
- 2020
26. Transcatheter ViV Versus Redo Surgical AVR for the Management of Failed Biological Prosthesis
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Maral Ouzounian, Mario Gaudino, Joanna Chikwe, Stephen E. Fremes, Peter C. Austin, Derrick Y. Tam, Harindra C. Wijeysundera, Christoffer Dharma, and Rodolfo V. Rocha
- Subjects
medicine.medical_specialty ,business.industry ,Proportional hazards model ,medicine.medical_treatment ,Hazard ratio ,Absolute risk reduction ,030204 cardiovascular system & hematology ,medicine.disease ,Prosthesis ,Confidence interval ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,McNemar's test ,Aortic valve replacement ,Propensity score matching ,medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objectives 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. Background 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. Methods 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. Results 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). Conclusions 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.
- Published
- 2020
27. Cerebral protection strategies in aortic arch surgery: A network meta-analysis
- Author
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Stephen E. Fremes, Irbaz Hameed, Michelle Demetres, Christopher Lau, Matthew Wingo, Antonino Di Franco, Leonard N. Girardi, Erin Iannacone, Mario Gaudino, Ashwin Palaniappan, Mohamed Rahouma, Derrick Y. Tam, Heather Anderson, and Faiza M. Khan
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,Odds ratio ,030204 cardiovascular system & hematology ,Aortic arch surgery ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Postoperative stroke ,030228 respiratory system ,Internal medicine ,Meta-analysis ,Circulatory system ,medicine ,Deep hypothermic circulatory arrest ,Cardiology ,Surgery ,Myocardial infarction ,Cerebral perfusion pressure ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objective Cerebral protection for aortic arch surgery has been widely studied, but comparisons of all the available strategies have rarely been performed. We performed direct and indirect comparisons of antegrade cerebral perfusion, retrograde cerebral perfusion, and deep hypothermic circulatory arrest in a network meta-analysis. Methods After a systematic literature search, studies comparing any combination of antegrade cerebral perfusion, retrograde cerebral perfusion, and deep hypothermic circulatory arrest were included, and a frequentist network meta-analysis was performed using the generic inverse variance method. The primary outcomes were postoperative stroke and operative mortality. Secondary outcomes were postoperative transient neurologic deficits, myocardial infarction, respiratory complications, and renal failure. Results A total of 68 studies were included with a total of 26,968 patients. Compared with deep hypothermic circulatory arrest, both antegrade cerebral perfusion and retrograde cerebral perfusion were associated with significantly lower postoperative stroke and operative mortality rates: antegrade cerebral perfusion (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.51-0.75; and OR, 0.63, 95% CI, 0.51-0.76, respectively) and retrograde cerebral perfusion (OR, 0.66; 95% CI, 0.54-0.82; and OR, 0.57; 95% CI, 0.45-0.71, respectively). Antegrade cerebral perfusion and retrograde cerebral perfusion were associated with similar incidence of primary outcomes. No difference among the 3 techniques was found in secondary outcomes. At meta-regression, circulatory arrest duration correlated with the neuroprotective effect of antegrade cerebral perfusion and retrograde cerebral perfusion compared with deep hypothermic circulatory arrest. Unilateral or bilateral antegrade cerebral perfusion and arrest temperature did not influence the results. Conclusions Antegrade cerebral perfusion and retrograde cerebral perfusion are associated with better postoperative outcomes compared with deep hypothermic circulatory arrest, and the relative benefit increases with the duration of the circulatory arrest. No differences between antegrade cerebral perfusion and retrograde cerebral perfusion were found for all the explored outcomes.
- Published
- 2020
28. Commentary: Let's not trade one problem for another: Moving beyond P values and confidence intervals
- Author
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Stephen E. Fremes and Derrick Y. Tam
- Subjects
Pulmonary and Respiratory Medicine ,business.industry ,Statistics ,Confidence Intervals ,Humans ,Medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Confidence interval - Published
- 2022
29. Commentary: What Happens to the Aorta in Bicuspid Aortic Valve Disease?
- Author
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Derrick Y. Tam, Maral Ouzounian, and Grace Lee
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Aorta ,business.industry ,General Medicine ,Disease ,medicine.disease ,Bicuspid aortic valve ,Treatment Outcome ,Bicuspid Aortic Valve Disease ,Internal medicine ,medicine.artery ,Aortic Valve ,medicine ,Cardiology ,Humans ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2021
30. Unmeasured, unknown, and hidden: Confounders are not always in plain sight
- Author
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Derrick Y. Tam, David J. Cohen, and Ahmad Makhdoum
- Subjects
Pulmonary and Respiratory Medicine ,Sight ,business.industry ,Environmental health ,Confounding ,MEDLINE ,Medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2022
31. Commentary: Finding delirium: It's harder than you think!
- Author
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Derrick Y. Tam, Stephen E. Fremes, and Dinela Rushani
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,MEDLINE ,medicine ,Delirium ,Humans ,Surgery ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,Psychiatry ,business - Published
- 2022
32. Commentary: Coronary artery bypass surgery and percutaneous coronary intervention: Optimal revascularization for the younger patient
- Author
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Derrick Y. Tam, Malak Elbatarny, Stephen E. Fremes, and Rodolfo V. Rocha
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Coronary artery bypass surgery ,business.industry ,Internal medicine ,medicine.medical_treatment ,medicine ,Cardiology ,Percutaneous coronary intervention ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Revascularization - Published
- 2022
33. Commentary: Microvesicles, personalized surgery, and tailored medical therapy to improve coronary artery bypass grafting outcomes
- Author
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Derrick Y. Tam and Stephen E. Fremes
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Bypass grafting ,business.industry ,Coronary Artery Disease ,Microvesicles ,Surgery ,medicine.anatomical_structure ,Humans ,Medicine ,Coronary Artery Bypass ,Cardiology and Cardiovascular Medicine ,business ,Medical therapy ,Artery - Published
- 2022
34. Surveillance Imaging Following Acute Type A Aortic Dissection
- Author
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Harindra C. Wijeysundera, Charles de Mestral, Thomas F. Lindsay, Jennifer Chung, Derrick Y. Tam, Maral Ouzounian, Feng Qiu, and Kevin R. An
- Subjects
Male ,Reoperation ,medicine.medical_specialty ,Population ,Long Term Adverse Effects ,Patient Care Planning ,Postoperative Complications ,Interquartile range ,medicine ,Humans ,Postoperative Period ,education ,Aortic dissection ,Ontario ,education.field_of_study ,medicine.diagnostic_test ,business.industry ,Mortality rate ,Incidence (epidemiology) ,Hazard ratio ,Magnetic resonance imaging ,Middle Aged ,medicine.disease ,Magnetic Resonance Imaging ,Confidence interval ,Surgery ,Aortic Aneurysm ,Aortic Dissection ,Female ,Guideline Adherence ,Cardiology and Cardiovascular Medicine ,business ,Tomography, X-Ray Computed ,Vascular Surgical Procedures ,Needs Assessment - Abstract
Background Survivors of acute type A aortic dissection (ATAAD) repair remain at risk for long-term complications. Guidelines recommend postoperative imaging surveillance, but adherence is uncertain. Objectives The aim of this study was to define the real-world frequency of postoperative imaging and characterize long-term outcomes of ATAAD. Methods Population-based administrative health databases for Ontario, Canada, were linked to identify patients who underwent ATAAD repair and survived at least 90 days. Guideline-directed imaging surveillance (GDIS) was defined as undergoing a computed tomographic or magnetic resonance imaging scan at 6 and 12 months postoperatively and then annually thereafter. Multivariable time-to-event analysis explored the associations between GDIS and all-cause mortality and reintervention. Results A total of 888 patients who survived urgent ATAAD repair between April 1, 2005, and March 31, 2018, were included. Median follow-up after ATAAD repair was 5.2 years (interquartile range: 2.4-7.9 years). A total of 14% patients received GDIS throughout follow-up. At 6 years, 3.9% of patients had received GDIS. The mortality rate was 4% at 1 year, 14% at 5 years, and 29% at 10 years. Incidence of aortic reintervention was 3% at 1 year, 9% at 5 years, and 17% at 10 years; the majority of these were urgent (68%), and they carried a 9% 30-day mortality rate. Greater adherence to GDIS was associated with mortality (hazard ratio: 1.08; 95% confidence interval: 1.05-1.11) and reintervention (hazard ratio: 1.04; 95% confidence interval: 1.01-1.07). Conclusions Adherence to GDIS following ATAAD repair is poor, while long-term mortality and reinterventions remain substantial. Further research is needed to determine if guidelines should be modified.
- Published
- 2021
35. Health Technology Assessment for Cardiovascular Digital Health Technologies and Artificial Intelligence: Why Is It Different?
- Author
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Harindra C. Wijeysundera, Derrick Y. Tam, and Dominique Vervoort
- Subjects
business.industry ,media_common.quotation_subject ,Biomedical Technology ,Cardiology ,Health technology ,Precision medicine ,Digital health ,Quality Improvement ,Telemedicine ,Scarcity ,Artificial Intelligence ,Health care ,Medicine ,Humans ,Quality (business) ,Applications of artificial intelligence ,Artificial intelligence ,Precision Medicine ,Cardiology and Cardiovascular Medicine ,business ,Delivery of Health Care ,Reimbursement ,media_common - Abstract
Innovations in health care are growing exponentially, resulting in improved quality of and access to care, as well as rising societal costs of care and variable reimbursement. In recent years, digital health technologies and artificial intelligence have become of increasing interest in cardiovascular medicine owing to their unique ability to empower patients and to use increasing quantities of data for moving toward personalised and precision medicine. Health technology assessment agencies evaluate the money spent on a health care intervention or technology to attain a given clinical impact and make recommendations for reimbursement considerations. However, there is a scarcity of economic evaluations of cardiovascular digital health technologies and artificial intelligence. The current health technology assessment framework is not equipped to address the unique, dynamic, and unpredictable value considerations of these technologies and highlight the need to better approach the digital health technologies and artificial intelligence health technology assessment process. In this review, we compare digital health technologies and artificial intelligence with traditional health care technologies, review existing health technology assessment frameworks, and discuss challenges and opportunities related to cardiovascular digital health technologies and artificial intelligence health technology assessment. Specifically, we argue that health technology assessments for digital health technologies and artificial intelligence applications must allow for a much shorter device life cycle, given the rapid and even potentially continuously iterative nature of this technology, and thus an evidence base that maybe less mature, compared with traditional health technologies and interventions.
- Published
- 2021
36. Commentary: Does the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score even matter?
- Author
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Stephen E. Fremes, Derrick Y. Tam, and Marc Ruel
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,biology ,Syntax (programming languages) ,business.industry ,biology.organism_classification ,Cardiac surgery ,Taxus ,Internal medicine ,Conventional PCI ,Cardiology ,Medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2021
37. More Reasons to Use the Radial Artery
- Author
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Derrick Y. Tam and Stephen E. Fremes
- Subjects
medicine.medical_specialty ,business.industry ,MEDLINE ,medicine.disease ,law.invention ,Coronary artery disease ,Randomized controlled trial ,law ,Physiology (medical) ,Internal medicine ,medicine.artery ,Radial Artery ,Cardiology ,Humans ,Medicine ,Saphenous Vein ,Coronary Artery Bypass ,Radial artery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2020
38. Microvesicles and Coronary Artery Bypass Graft Patency
- Author
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Stephen E. Fremes and Derrick Y. Tam
- Subjects
medicine.medical_specialty ,Graft patency ,business.industry ,Thrombin generation ,Microvesicles ,Surgery ,medicine.anatomical_structure ,Graft occlusion ,medicine ,Vascular Patency ,Platelet ,Cardiology and Cardiovascular Medicine ,business ,Artery - Published
- 2020
39. Commentary: The Best Choice for the Second Graft: The Graft Patency Evidence Revisited
- Author
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Derrick Y. Tam and Stephen E. Fremes
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Graft patency ,business.industry ,General Medicine ,Surgery ,Treatment Outcome ,Text mining ,medicine ,Humans ,Coronary Artery Bypass ,Cardiology and Cardiovascular Medicine ,business ,Vascular Patency - Published
- 2022
40. People With Injection Drug Use–Associated Endocarditis
- Author
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Bobby Yanagawa, Derrick Y. Tam, and Kevin R. An
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Endocarditis ,business.industry ,medicine.disease ,Injection drug use ,Text mining ,Pharmaceutical Preparations ,medicine ,Humans ,Surgery ,Substance Abuse, Intravenous ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business - Published
- 2022
41. Commentary: A Puzzle With Many 'Moving' Parts
- Author
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Stephen E. Fremes, Mimi X. Deng, and Derrick Y. Tam
- Subjects
Pulmonary and Respiratory Medicine ,Moving parts ,business.industry ,Medicine ,Surgery ,General Medicine ,Cardiology and Cardiovascular Medicine ,business ,Data science - Published
- 2022
42. A Systematic Review and Meta-Analysis of del Nido Versus Conventional Cardioplegia in Adult Cardiac Surgery
- Author
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Ishtiaq A. Rahman, Bobby Yanagawa, Subodh Verma, Niv Ad, David A. Latter, Derrick Y. Tam, Stephen E. Fremes, and Kevin R. An
- Subjects
Adult ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,General Medicine ,030204 cardiovascular system & hematology ,Cardiac surgery ,03 medical and health sciences ,0302 clinical medicine ,030228 respiratory system ,Internal medicine ,Meta-analysis ,Heart Arrest, Induced ,medicine ,Cardiology ,Humans ,Surgery ,Cardiac Surgical Procedures ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objective Del Nido cardioplegia (DC) has been used extensively in pediatric cardiac surgery but the efficacy and safety in adults remains uncertain. Our objective was to perform a systematic review and meta-analysis comparing DC and blood cardioplegia (BC) in our primary endpoint of 30-day or in-hospital mortality as well as other efficacy and safety endpoints. Methods Both MEDLINE and EMBASE were searched from 1996 to 2017 for studies comparing DC and BC. Data were extracted by 2 independent investigators and aggregated in a random effects model. Results One randomized controlled trial ( n = 89), 7 adjusted ( n = 1,104), and 5 unadjusted observational studies ( n = 717) were included. There was no difference in in-hospital mortality between DC and BC (relative risk:0.67, 95% confidence interval [CI]: 0.22, 2.07; P = 0.49). DC reduced cardioplegia volume requirements (mean difference [MD]:−1.1 L, 95% CI, −1.6, −0.6; P < 0.0001), aortic cross-clamp time (MD: −8 minutes, 95% CI, −12, −3; P = 0.0004), and cardiopulmonary bypass (CPB) times (MD: −8 minutes, 95% CI, −14, −3; P = 0.03). DC reduced troponin release (standardized MD: −0.3, 95% CI, −0.5, −0.1; P = 0.001). In-hospital outcomes of stroke, atrial fibrillation, acute kidney injury/dialysis, low cardiac output state, blood transfusion, reoperation rate, postoperative left ventricular EF, intensive care unit length of stay (LOS), and in-hospital LOS were comparable between groups. Conclusions DC is a safe alternative to BC in routine adult cardiac surgery. Its use is associated with reduction in CPB and aortic cross-clamp times and may potentially offer improved myocardial protection.
- Published
- 2019
43. Aortic Root Enlargement Is Safe and Reduces the Incidence of Patient-Prosthesis Mismatch: A Meta-analysis of Early and Late Outcomes
- Author
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Derrick Y. Tam, Maral Ouzounian, Rodolfo V. Rocha, Wanqing Yu, Ahmad Makhdoum, and Stephen E. Fremes
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Aorta, Thoracic ,030204 cardiovascular system & hematology ,Prosthesis Design ,Prosthesis ,law.invention ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,0302 clinical medicine ,Aortic valve replacement ,law ,Internal medicine ,medicine ,Cardiopulmonary bypass ,Humans ,030212 general & internal medicine ,Adverse effect ,business.industry ,Aortic Valve Stenosis ,medicine.disease ,Confidence interval ,3. Good health ,Cardiothoracic surgery ,Aortic Valve ,Heart Valve Prosthesis ,Relative risk ,Meta-analysis ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Aortic root enlargement (ARE) may be an important adjunct to aortic valve replacement (AVR) to prevent patient-prosthesis mismatch and facilitate future valve-in-valve transcatheter AVR (TAVR). However, the early safety and late benefits of adding surgical ARE to AVR remain controversial.MEDLINE and EMBASE were searched from 1946 to 2018 for articles comparing patients undergoing AVR+ARE with those undergoing AVR alone. A random-effects meta-analysis was performed to compare early and late clinical outcomes.A total of 2570 AVR+ARE and 5,991 AVR patients were included from 9 observational studies. There was no difference in early mortality (relative risk [RR] 1.21; 95% confidence interval [CI], 0.94-1.54; P = 0.13). Both cardiopulmonary bypass (mean difference [MD] 20 minutes; 95% CI, 15-25; P0.01) and aortic cross-clamp time (MD 14 minutes; 95% CI, 11-17, P0.01) were higher following AVR+ARE. There was no difference in the risk of permanent pacemaker implantation (RR 1.02; 95% CI, 0.83-1.25; P = 0.86), reoperation for bleeding (RR 1.05; 95% CI, 0.84-1.32; P = 0.64), or stroke (RR 0.93; 95% CI, 0.68-1.27; P = 0.65). The risk of moderate (indexed effective orifice area [iEOA]0.85 cmSurgical ARE is a safe adjunct to AVR in selected patients that does not increase early adverse events and results in less patient-prosthesis mismatch. This strategy allows for a larger valve size at the time of implantation, an important consideration for potential future valve-in-valve procedures in the era of TAVR.
- Published
- 2019
44. Bilateral versus single internal thoracic artery for coronary artery bypass grafting with end‐stage renal disease: A systematic review and meta‐analysis
- Author
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Kevin R. An, Derrick Y. Tam, Mario Gaudino, Stephen E. Fremes, Mohamed Rahouma, and Reena Karkhanis
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Coronary Artery Disease ,Internal thoracic artery ,030204 cardiovascular system & hematology ,Rate ratio ,End stage renal disease ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Internal medicine ,medicine ,Humans ,Coronary Artery Bypass ,Mammary Arteries ,Stroke ,Dialysis ,business.industry ,medicine.disease ,Databases, Bibliographic ,Confidence interval ,Survival Rate ,Treatment Outcome ,030228 respiratory system ,Meta-analysis ,Cardiology ,Kidney Failure, Chronic ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background The incidence of severe coronary artery disease (CAD) in patients with end-stage renal disease (ESRD) on dialysis is high. Coronary artery bypass grafting (CABG) is the preferred treatment in those with severe CAD. Bilateral internal thoracic artery (BITA) vs single internal thoracic artery (SITA) grafting has been shown to improve late survival in other high-risk populations. In ESRD, comparative studies are limited by sample size to detect outcome differences. We sought to determine the late survival and early outcomes of BITA compared with SITA in patients with ESRD. Methods MEDLINE and EMBASE were searched from inception to 2017 for studies directly comparing BITA to SITA in patients with ESRD undergoing CABG. The primary outcome was late survival; secondary outcomes were in-hospital/30-day mortality, stroke, and deep sternal wound infection (DSWI). Kaplan-Meier curve reconstruction for late mortality was performed. Results Five studies (three adjusted [n = 197] and two unadjusted observational studies [n = 231]) were included in the analysis. Reported ITA skeletonization ranged from 83% to 100% (median: 100%). There was no difference in in-hospital mortality (risk risk [RR], 0.84; 95% confidence interval [95%CI], 0.36,1.98; P = 0.70), perioperative stroke (RR, 1.97; 95%CI, 0.58,6.66; P = 0.28), and DSWI (RR, 1.56; 95%CI, 0.60,4.07; P = 0.36) between BITA and SITA. All studies reported adjusted late mortality, which was similar between BITA and SITA (incident rate ratio, 0.81; 95%CI, 0.59,1.11) at mean 3.7-year follow-up. Conclusions BITA grafting is safe in patients with ESRD although there was no survival benefit at 3.7 years. Additional studies with longer follow-up are required to determine the potential late benefits of BITA grafting in patients with ESRD.
- Published
- 2019
45. Tricuspid valve intervention at the time of mitral valve surgery: a meta-analysis
- Author
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Andrew Tran, Amine Mazine, Derrick Y. Tam, Antonio M. Calafiore, Gilbert H.L. Tang, Mario Gaudino, Stephen E. Fremes, and Jan O. Friedrich
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Tricuspid valve ,business.industry ,Perioperative ,030204 cardiovascular system & hematology ,Rate ratio ,Confidence interval ,law.invention ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,Randomized controlled trial ,Tricuspid Valve Insufficiency ,law ,Relative risk ,Mitral valve ,medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business - Abstract
OBJECTIVES The surgical management of tricuspid regurgitation (TR) at the time of mitral valve surgery remains controversial. Our objectives were to determine the safety and efficacy of tricuspid valve (TV) repair during mitral valve surgery in a meta-analysis. METHODS MEDLINE and EMBASE were searched from 1946 to 2017 for all studies comparing TV repair to no intervention at the time of mitral valve surgery on early and late mortality and late TR. A random-effects meta-analysis of all outcomes was performed. RESULTS One thousand four hundred and seventeen studies were retrieved and a total of 17 studies [2 randomized clinical trial (n = 211), 11 adjusted observational studies (n = 3848) and 4 unadjusted observational studies (n = 67 010)] that compared TV repair (n = 11 787) to no intervention (n = 56 027) at a mean follow-up of 6.0 ± 0.64 years were included. There was no difference in 30-day/in-hospital mortality between repair and no repair [risk ratio (RR) 1.19, 95% confidence interval (95% CI) 0.70–2.02; P = 0.52]. The incidence of new permanent pacemaker implantation was higher in the TV repair group (RR 2.73, 95% CI 2.57–2.89; P CONCLUSIONS TV repair appears safe in the perioperative period and may reduce future recurrent TR without any survival benefit.
- Published
- 2019
46. The state of transcatheter aortic valve implantation training in Canadian cardiac surgery residency programs
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Stephen E. Fremes, Ahmed Makhdoum, Derrick Y. Tam, Harindra C. Wijeysundera, Maral Ouzounian, and Gideon Cohen
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Canada ,medicine.medical_specialty ,Transcatheter aortic ,Attitude of Health Personnel ,education ,030204 cardiovascular system & hematology ,Simulation training ,Physician Executives ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,0302 clinical medicine ,Surveys and Questionnaires ,Humans ,Medicine ,Competence (human resources) ,Fellowship training ,Curriculum ,business.industry ,Research ,Internship and Residency ,Cardiac surgery ,030228 respiratory system ,General Surgery ,Family medicine ,Surgery ,Thematic analysis ,business ,Residency training - Abstract
The current state of transcatheter aortic valve implantation (TAVI) training for Canadian cardiac surgical residents is unknown. Our goals were to establish a national inventory of TAVI educational resources, elucidate the role of residents in TAVI programs, and determine the attitudes and perspectives of residents and program directors regarding the importance of TAVI technology and training.We sent Web-based surveys and reminders to all Canadian cardiac surgical residents and program directors between February and July 2017. We used descriptive analyses to summarize data in an aggregate and anonymous manner. We analyzed patterned responses to open-ended survey questions using thematic analysis.Seventy-eight of 92 residents (85%) and 11 of 12 program directors (92%) completed the survey, with broad representation from across Canada. A minority of residents (14 [18%]) and program directors (4 [36%]) reported that TAVI training in their program was adequate. Only 3 program directors (27%) reported that their residents had access to TAVI simulation training. Although most residents (76 [97%]) and program directors (10 [91%]) agreed that TAVI was important to the trainee's future practice, about two-thirds (54 [69%] and 7 [64%], respectively) agreed that TAVI should be a focus of fellowship training. A perceived lack of interest from interventional cardiologists to teach surgical residents, competition from TAVI fellows and lack of formalized time during residency were identified as perceived barriers to TAVI training.As Canadian surgical residency training moves toward a Competence by Design curriculum, there remains a pressing need to create uniform learning objectives and expectations in the TAVI curriculum.On ne connaît pas l'état actuel de la formation en implantation transcathéter de valvule aortique (ITVA) que reçoivent les médecins résidents dans les programmes canadiens de chirurgie cardiaque. Nous voulions dresser un inventaire national des ressources pédagogiques en ITVA, expliquer le rôle des médecins résidents dans les programmes d'ITVA et déterminer les attitudes et les points de vue des résidents et des directeurs de programme quant à l'importance de la technologie d'ITVA et de la formation en la matière.Entre février et juillet 2017, nous avons envoyé des sondages web et des rappels à tous les médecins résidents en chirurgie cardiaque et aux directeurs de ces programmes au Canada. Nous avons utilisé des analyses descriptives pour résumer les données de façon agrégée et anonyme. Nous avons analysé les réponses à des questions ouvertes et dégagé des tendances au moyen d'une analyse thématique.Soixante-dix-huit des 92 résidents (85 %) et 11 des 12 directeurs de programme (92 %) ont répondu au sondage, avec une vaste représentation de partout au Canada. Une minorité de résidents (14 [18 %]) et de directeurs de programme (4 [36 %]) ont déclaré que la formation en ITVA offerte par leur programme était adéquate. Seuls 3 directeurs de programme (27 %) ont déclaré que leurs résidents avaient accès à une formation en simulation de l'ITVA. Bien que la plupart des résidents (76 [97 %]) et des directeurs de programme (10 [91 %]) soient d'accord pour dire que l'ITVA est importante pour la pratique future du stagiaire, environ les deux tiers (54 [69 %] et 7 [64 %], respectivement) sont d'avis que la formation à l'ITVA devrait faire l'objet d'un stage particulier. Un manque perçu d'intérêt de la part des cardiologues interventionnels pour l'enseignement aux médecins résidents en chirurgie, la compétition entre les stagiaires pour la formation à l'ITVA et le manque de temps officiellement réservé à ce volet pendant la résidence ont été identifiés comme des obstacles perçus à la formation en ITVA.À mesure que les programmes de résidence en chirurgie au Canada s'orientent vers une formation axée sur les compétences par conception, il demeure urgent de formuler des objectifs et des attentes d'apprentissage uniformes pour la formation en ITVA.
- Published
- 2018
47. Meta-Analysis Comparing Outcomes of Drug Eluting Stents Versus Single and Multiarterial Coronary Artery Bypass Grafting
- Author
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Mario Gaudino, Umberto Benedetto, Michael P. Vallely, Derrick Y. Tam, Jeremy R. Leonard, Antonino Di Franco, Mario Iannaccone, Leonard N. Girardi, Mohamed Rahouma, Stephen E. Fremes, Giuseppe Biondi-Zoccai, Ahmed Abouarab, Fabrizio D'Ascenzo, and David P. Taggart
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Global Health ,Prosthesis Design ,Rate ratio ,Revascularization ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Clinical endpoint ,Humans ,030212 general & internal medicine ,Coronary Artery Bypass ,business.industry ,Drug-Eluting Stents ,Odds ratio ,Confidence interval ,Survival Rate ,Treatment Outcome ,Drug-eluting stent ,Meta-analysis ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Relative benefits of coronary artery bypass (CABG) using single and multiple arterial grafting (SAG, MAG) and drug eluting stent (DES) in multivessel coronary disease remain uncertain. We compared SAG, MAG, and DES in a pairwise and network meta-analysis. Randomized trials and adjusted observational studies comparing CABG versus DES were included (primary end point: long-term mortality; secondary end points: operative mortality, perioperative stroke, and follow-up repeated revascularization [RR]). Studies with ≥1.7 arterial grafts and/or patient were classified as MAG. Bayesian network meta-analyses and random-model pairwise meta-analyses were performed. A total of 53,239 patients (8 randomized, 17 observational studies) were included (26,306 DES; 26,933 CABG). In pairwise comparison (mean follow-up: 5.42 years), CABG (MAG + SAG) was associated with lower long-term mortality (incident rate ratio [IRR] 0.77, 95% confidence interval [CI] 0.66 to 0.90), lower RR (IRR 0.37, 95% CI 0.27 to 0.51), increased perioperative stroke (odds ratio [OR] 3.18, 95% CI 1.70 to 5.97), and similar operative mortality (OR 1.04, 95% CI 0.64 to 1.70) compared with DES. There was a nonsignificant trend toward lower long-term mortality for studies with higher mean number of arterial grafts. In network meta-analyses, compared with DES, MAG was associated with lower long-term mortality (IRR 0.72, 95% credible interval [CrI] 0.57 to 0.92) and late RR (IRR 0.32, 95% CrI 0.21 to 0.49), SAG was associated with lower long-term mortality and RR (IRR 0.80, 95% CrI 0.66 to 0.97 and IRR 0.42, 95% CrI 0.29 to 0.61, respectively). In conclusion, CABG was associated with reduced 5-year mortality and need for RR compared with DES. MAG was ranked as the best treatment for the primary and all secondary outcomes.
- Published
- 2018
48. Multiple Arterial Grafting Is Associated With Better Outcomes for Coronary Artery Bypass Grafting Patients
- Author
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Reena Karkhanis, Rashmi Nedadur, Mario Gaudino, Stephen E. Fremes, Jiming Fang, Rodolfo V. Rocha, Alistair Royse, Jack V. Tu, and Derrick Y. Tam
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Male ,Reoperation ,medicine.medical_specialty ,Time Factors ,Databases, Factual ,Bypass grafting ,Myocardial Infarction ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Risk Assessment ,Clinical study ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Physiology (medical) ,Humans ,Medicine ,In patient ,Hospital Mortality ,Registries ,Coronary Artery Bypass ,Aged ,Retrospective Studies ,Ontario ,business.industry ,Middle Aged ,Arterial grafting ,Surgery ,Stroke ,Arterial grafts ,Treatment Outcome ,medicine.anatomical_structure ,030228 respiratory system ,Female ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Background: Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG). Methods: Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching. Results: Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P P =0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94–1.25), death (HR, 1.08; 95% CI, 0.90–1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87–1.51), stroke (HR, 1.39; 95% CI, 0.95–2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82–1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77–0.88), survival (HR, 0.80; 95% CI, 0.73–0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69–0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72–0.97) were superior in the MAG group. Conclusions: CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.
- Published
- 2018
49. Commentary: Until we take it seriously, the status quo of postoperative atrial fibrillation management will prevail
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Derrick Y. Tam, Grace Lee, and Stephen E. Fremes
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Status quo ,business.industry ,media_common.quotation_subject ,medicine ,Surgery ,Atrial fibrillation ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,medicine.disease ,business ,media_common - Published
- 2021
50. Commentary: Deus ex machina: Bad coding or perfect plot device?
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Derrick Y. Tam, Hillary Lia, and Stephen E. Fremes
- Subjects
Pulmonary and Respiratory Medicine ,Deus ,business.industry ,Medicine ,Surgery ,Plot (narrative) ,Theology ,Cardiology and Cardiovascular Medicine ,business ,Coding (social sciences) - Published
- 2021
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