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Modeling Quality Standards with Decision Analysis in Medicine and Public Health
Published in Donald B. Owen, Subir Ghosh, William R. Schucany, William B. Smith, Statistics of Quality, 2020
Consider the decision problem involving a choice between surgery, decision SUR, and medical care with watchful waiting, decision MED. Assume that it is uncertain whether or not the condition of the patient is such that surgery would be helpful. Let DIS represent the presence of the disease state for which the surgery contemplated is targeted, and let DIS¯ denote its absence. Suppose that after an initial examination the physician assesses the probability of DIS as 0.6, with the probability of DIS¯ = 0.4.
Mitral valve surgery: current status and future prospects of the minimally invasive approach
Published in Expert Review of Medical Devices, 2021
Karel M. Van Praet, Jörg Kempfert, Stephan Jacobs, Christof Stamm, Serdar Akansel, Markus Kofler, Simon H. Sündermann, Timo Z. Nazari Shafti, Katharina Jakobs, Stefan Holzendorf, Axel Unbehaun, Volkmar Falk
Current guidelines recommend, surgical treatment of chronic MR in symptomatic patients with severe primary MR [4,8], as depicted in Figure 1. Signs of ongoing left ventricular (LV) remodeling (LV end-systolic diameter (LVESD) ≥ 45 mm or LV ejection fraction (LVEF) ≤ 60%), right ventricular (RV) impairment and pulmonary hypertension (systolic pulmonary pressure ≥50 mmHg), and left atrial (LA) remodeling (atrial fibrillation (AF) predict worse postoperative outcomes, independent of the symptomatic status, and hence have become triggers for early surgery in asymptomatic patients [4]. Regarding asymptomatic patients, there is ongoing debate about the ideal timing for intervention [2,9]. Some groups prefer a watchful waiting strategy with very strict follow-up and echo assessment; others promote early intervention as is recommended in the 2017 European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines for the management of VHD [2,8]. Urgent surgery in primary MR is only required for patients with acute severe MR resulting from an acute papillary muscle or chordal rupture or in infective endocarditis (IE) of the MV [4,10].
How valvular calcification can affect the outcomes of transcatheter aortic valve implantation
Published in Expert Review of Medical Devices, 2020
Stephan Milhorini Pio, Jeroen Bax, Victoria Delgado
The relevance of assessing the aortic valve calcification prior to TAVI will be demonstrated in ongoing studies including patients in whom a watchful waiting strategy and medical therapy are currently the standard of care, unless there are other concomitant conditions that need cardiac surgery (for example, coronary revascularization). While accurate measurement of the aortic valve annulus to select the prosthesis size and accurate assessment of the femoral artery anatomy remain key to ensure successful transfemoral TAVI, the amount of aortic valve calcification may impact on the results of this therapy. It is worthy to point out that current guidelines on the management of valvular heart disease recommend that SAVR must be preferred in patients with acceptable surgical risk when valve morphology characteristics, such as degree of calcification and calcification pattern, are unfavorable to TAVI [14].
Diagnosis, treatment & management of prosthetic valve thrombosis: the key considerations
Published in Expert Review of Medical Devices, 2020
Sabahattin Gündüz, Macit Kalçık, Mustafa Ozan Gürsoy, Ahmet Güner, Mehmet Özkan
Treatment options for PHVT include intensified anticoagulation, TT, and surgery [7–9,65]. In certain high-risk patients with prohibitive risks to surgery and contraindications to TT, only watchful waiting may remain as the last option. The effectiveness of anticoagulation in the resolution of PHVT is based on data from a limited number of publications [21,66–70]. The prognosis has been reported to be favorable with optimization of anticoagulant treatment [short-term intravenous unfractionated heparin (UFH) followed by warfarin adjustment and aspirin addition] for small asymptomatic thrombi (length <10 mm) [69]. A previous publication depicted the effectiveness of prolonged UFH infusion with subsequent oral anticoagulation in preventing embolic events in patients with early nonobstructive PHVT of size <5 mm after mitral prosthetic heart valve replacement [68]. Recently, we reported that UFH could be successful in 46.8% of PHVT patients who had relative contraindications to both TT and surgery [21]. In current literature, the use of low-molecular-weight heparin in left-sided PHVT is not clear yet.