A Sneak-Peek into the Physician's Brain: A Retrospective Machine Learning-Driven Investigation of Decision-Making in TAVR versus SAVR for Young High-Risk Patients with Severe Symptomatic Aortic Stenosis.
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SUBMITTER: Hasimbegovic E
PROVIDER: S-EPMC8622882 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceShared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM.ObjectiveTo determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs.Design, setting, and participantsThis mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management.Main outcomes and measuresClinician SDM performance was measured using the Observer OPTION5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed.ResultsSix male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P?<?.001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P?=?.04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P?=?.01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P?=?.60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk.Conclusion and relevanceIn a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.
| S-EPMC7160688 | biostudies-literature
Project description:AimTo provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL].MethodsA questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment.ResultsAll 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients' functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres 'often to always' do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are 'sometimes to regularly' available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed 'sometimes to regularly' in heart team meetings (n = 10).ConclusionsDutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.
| S-EPMC9402830 | biostudies-literature
Project description: Not available
| S-EPMC10715983 | biostudies-literature
Project description:BackgroundLittle is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center.ObjectiveWe identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients' perceptions of their involvement and satisfaction with treatment selection.Methods and resultsOf 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P<0.001). Physician-reported reasons for medical management included patient preference (31.0%), medical futility (19.7%), inoperability/anatomic infeasibility (11.3%), and inadequate vascular access (8.5%). Compared with patients receiving AVR, medically managed patients were less likely to report that they received enough information about the pros and cons of treatment options (P = 0.03), that their physicians involved them in treatment decisions (P<0.001), and that final decisions were the right ones (P<0.001).ConclusionsPatient preference was the most common physician-reported reason for selecting non-invasive AS management, yet patients not undergoing AVR after valve center evaluation reported being less likely to receive sufficient education about treatment options and more likely to feel uncertain about final treatment decisions. Greater attention to shared decision making may improve the experience of care for this vulnerable group of patients.
| S-EPMC5400246 | biostudies-literature
Project description:Background: Despite clear indications for intervention, therapeutic decision-making for elderly patients with severe symptomatic aortic stenosis (AS) remains a complex issue due to the wide variation in individual risk profiles and the involvement of patients' subjective preferences. We aimed to investigate the reasons leading to the decisions against intervention and the consequences thereof on survival. Methods: Data were derived from the China Elderly Valve Disease (China-DVD) Cohort Study on patients aged ≥60-year-old with severe symptomatic AS consecutively enrolled between September to December 2016. Patients were analyzed according to the initial therapeutic decisions made by consensus between patients and physicians at the time of the index evaluation: intervention group (patients who were evaluated as suitable for intervention and accepted the treatment proposal); patient-refusal group (patients who were evaluated as suitable for intervention but refused due to subjective preferences); physician-deny group (patients who were denied intervention by physicians after evaluation). The least absolute shrinkage and selection operator (LASSO)-penalized logistic regression model was used to identify the factors associated with physicians' decisions against intervention. Twelve-month survival was analyzed using Cox proportional hazards models, with multivariate adjustment using inverse probability weighting (IPW). Results: Among the enrolled 456 elderly patients with severe symptomatic AS, 52 (11.4%) patients refused intervention and 49 (10.7%) patients were denied intervention by their physicians. LASSO-penalized logistic regression model identified that reduced left ventricular ejection fraction and increased EuroSCORE-II were strongly associated with physicians' decisions against intervention. At 12-month follow-up, only 8 (15.4%) patients who initially refused the intervention proposal underwent the subsequent intervention, with an average delay of 195 days. Patients' initial decisions against intervention were significantly associated with 12-month mortality, even after IPW adjustment (Hazard ratio: 2.61; 95% confidence interval: 1.09-6.20; P = 0.031). Conclusions: The decision against intervention was taken in about one-fifth of elderly patients with symptomatic severe AS, half of which were due to patients' subjective preferences. Surgical risk remains the primary concern for physicians when making therapeutic decisions. Elderly patients' initial decisions against intervention have a profound impact on subsequent intervention rates and prognosis, and therefore should be treated as a "risk factor" at the subjective level. Clinical Trial Registration: clinicaltrials.gov/ct2/show/NCT02865798, China elDerly Valve Disease (China-DVD) cohort study (NCT02865798).
| S-EPMC8350052 | biostudies-literature
Project description:BackgroundTranscatheter aortic valve replacement (TAVR) was initially introduced to treat patients with aortic valve stenosis (AS) at high-risk for surgical aortic valve replacement (SAVR). Today, there is ample evidence supporting TAVR in high-risk groups. However, in recent years TAVR has been extended to low-to intermediate risk groups and relevant clinical evidence is still emerging, leaving some uncertainties.MethodsTo obtain information on TAVR versus SAVR in low-to intermediate risk groups, we conducted an overview of systematic reviews following PRISMA guidelines and based on a systematic search of EMBASE, MEDLINE, Cochrane and CRD databases. We focused on systematic reviews assessing mortality and VARC 2 as clinical outcomes.ResultsThe majority of the 11 systematic reviews included in our study reported no differences in mortality between TAVR and SAVR at short and long-term follow-up times. Two reviews that included the most recent RCTs on low-risk patients reported a decreased mortality risk with TAVR at one-year follow-up. Regarding the secondary endpoints of stroke and MI, the majority of studies presented similar results for TAVR and SAVR. Acute Kidney Injury, Bleeding Complications, Atrial Fibrillation were less frequent with TAVR, with lower risk of Permanent Pacemaker Implantation and Aortic Regurgitation with SAVR.ConclusionsOur overview indicated that TAVR is a promising intervention for low-to-intermediate surgical risk patients; however additional evidence from longer term follow-up is needed to confirm these findings. This overview highlights inconsistencies about reporting and presentation of data, most notably limited clarity on effects of risk of bias on trial results.
| S-EPMC7322533 | biostudies-literature
Project description:A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.
| S-EPMC4382556 | biostudies-literature
Project description:Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.
| S-EPMC6880229 | biostudies-literature
Project description:Transcatheter aortic valve replacement in surgical aortic valve is a safe and effective procedure to treat patients with failed bioprosthetic surgical valves at high risk for reoperation. Performing bioprosthetic valve fracture has been shown to improve postprocedural hemodynamics of TAVR in surgical aortic valve replacement. However, specific complications related to valve fracture are becoming more common. (Level of Difficulty: Advanced.).
| S-EPMC9666742 | biostudies-literature
Project description:BackgroundPhysiotherapy prior to open-heart surgery lowers the rate of pneumonia and length of the hospital stay. Pneumonia is a major contributor to short-term mortality following transcatheter aortic valve replacement (TAVR). Hence, we hypothesized that pre- and intensified postprocedural physiotherapy in patients undergoing TAVR might impact the net functional and clinical outcome.Methods and resultsThe 4P-TAVR study was a prospective, monocentric, randomized trial. The study was designed to compare the efficacy and safety of intensified periprocedural physiotherapy including inspiratory muscle training versus standard postprocedural physiotherapy. Patients were randomized in a 1 : 1 fashion. 108 patients were included and followed up for 90 days after TAVR. While patients in group A (control group: 50 patients, age: 81.7 ± 5.0 years, 52% male) did not receive physiotherapy prior to TAVR, group B (intervention group: 58 patients, age: 82.2 ± 5.82 years, 47% male) participated in intensive physiotherapy. Compared to the control group, patients in the interventional group showed a lower incidence of postinterventional pneumonia (10 [20.0%] vs. 3 [5.1%], p=0.016) and had a 3-day shorter mean hospital stay (13.5 ± 6.1 days vs. 10.1 ± 4.7 days, p=0.02). The primary composite endpoint of mortality and rehospitalization was not different between the groups.ConclusionIntensified physiotherapy is safe and has positive effects on clinical outcomes up to 90 days after TAVR but has no impact on the primary combined endpoint of mortality and rehospitalization. Longer follow-up, a multicenter design, and a higher number of subjects are needed to confirm these preliminary results. This trial is registered with DRKS00017239.
| S-EPMC7826236 | biostudies-literature