Showing papers by "Manuel J. Antunes published in 2015"

2015 ESC Guidelines for the management of infective endocarditis

Abstract: 3D : three-dimensional AIDS : acquired immune deficiency syndrome b.i.d. : bis in die (twice daily) BCNIE : blood culture-negative infective endocarditis CDRIE : cardiac device-related infective endocarditis CHD : congenital heart disease CIED : cardiac implantable electronic device

2015 ESC Guidelines for the management of infective endocarditis

Abstract: Authors/Task Force Members: Gilbert Habib* (Chairperson) (France), Patrizio Lancellotti* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal), Maria Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zotti (Italy), Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erba (Italy), Bernard Iung (France), Jose M. Miro (Spain), Barbara J. Mulder (The Netherlands), Edyta Plonska-Gosciniak (Poland), Susanna Price (UK), Jolien Roos-Hesselink (The Netherlands), Ulrika Snygg-Martin (Sweden), Franck Thuny (France), Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)

Secondary tricuspid valve regurgitation: a forgotten entity

Abstract: ### Learning objectives The tricuspid valve was virtually ignored for a long time in the past. However, the incidence of tricuspid insufficiency associated with left valvular disease is quite significant, ranging from 8% to 35% of cases.1 ,2 This is most common in conjunction with mitral valve disease but association with aortic valve pathology is not uncommon. It is most frequently related to rheumatic valve disease and much rarer in association with degenerative mitral valve disease. In most cases, the tricuspid regurgitation (TR) is so-called ‘functional’, corresponding to dilatation of the annulus, as a consequence of RV dilatation secondary to pulmonary hypertension. In 15–20% of cases, however, the injury can be organic, generally of rheumatic origin, but for the purposes of this work we will restrict our analysis to secondary (terminology now preferred over functional) TR. Originally, it was thought that in most patients with secondary TR, surgical treatment of the mitral valve disease would correct the problems of the right side and, hence, a conservative (no touch) approach to the tricuspid valve was recommended.3 ,4 More recently, however, it has become evident that in a significant number of cases secondary TR does not regress after appropriate correction of the left-side valvulopathy. Thus, the indications for surgery of the TR have moved towards a progressively more interventional attitude. Today, it is evident that we must intervene on the tricuspid valve in cases of obviously severe tricuspid insufficiency and in cases where perioperative detection of a more significant TR than expected is made, especially when triggered by increasing load conditions.5 ,6 In this work, we intend to review the current …

Assessment of cardiovascular function from multi-Gaussian fitting of a finger photoplethysmogram.

Abstract: Monitoring of cardiovascular function on a beat-to-beat basis is fundamental for protecting patients in different settings including emergency medicine and interventional cardiology, but still faces technical challenges and several limitations. In the present study, we propose a new method for the extraction of cardiovascular performance surrogates from analysis of the photoplethysmographic (PPG) signal alone.We propose using a multi-Gaussian (MG) model consisting of five Gaussian functions to decompose the PPG pulses into its main physiological components. From the analysis of these components, we aim to extract estimators of the left ventricular ejection time, blood pressure and vascular tone changes. Using a multi-derivative analysis of the components related with the systolic ejection, we investigate which are the characteristic points that best define the left ventricular ejection time (LVET). Six LVET estimates were compared with the echocardiographic LVET in a database comprising 68 healthy and cardiovascular diseased volunteers. The best LVET estimate achieved a low absolute error (15.41 ± 13.66 ms), and a high correlation (ρ = 0.78) with the echocardiographic reference.To assess the potential use of the temporal and morphological characteristics of the proposed MG model components as surrogates for blood pressure and vascular tone, six parameters have been investigated: the stiffness index (SI), the T1_d and T1_2 (defined as the time span between the MG model forward and reflected waves), the reflection index (RI), the R1_d and the R1_2 (defined as their amplitude ratio). Their association to reference values of blood pressure and total peripheral resistance was investigated in 43 volunteers exhibiting hemodynamic instability. A good correlation was found between the majority of the extracted and reference parameters, with an exception to R1_2 (amplitude ratio between the main forward wave and the first reflection wave), which correlated low with all the reference parameters. The highest correlation ([Formula: see text] = 0.45) was found between T1_2 and the total peripheral resistance index (TPRI); while in the patients that experienced syncope, the highest agreement ([Formula: see text] = 0.57) was found between SI and systolic blood pressure (SBP) and mean blood pressure (MBP).In conclusion, the presented method for the extraction of surrogates of cardiovascular performance might improve patient monitoring and warrants further investigation.

Outcome after heart transplantation from older donor age: expanding the donor pool

Abstract: OBJECTIVES: There has been a progressive expansion of heart donor selection criteria, including higher age limit. We analysed the impact of using hearts from older age donors (>50 years).

Prediction of Heart Failure Decompensation Events by Trend Analysis of Telemonitoring Data

Abstract: This paper aims to assess the predictive value of physiological data daily collected in a telemonitoring study in the early detection of heart failure (HF) decompensation events. The main hypothesis is that physiological time series with similar progression (trends) may have prognostic value in future clinical states (decompensation or normal condition). The strategy is composed of two main steps: a trend similarity analysis and a predictive procedure. The similarity scheme combines the Haar wavelet decomposition, in which signals are represented as linear combinations of a set of orthogonal bases, with the Karhunen–Loeve transform, that allows the selection of the reduced set of bases that capture the fundamental behavior of the time series. The prediction process assumes that future evolution of current condition can be inferred from the progression of past physiological time series. Therefore, founded on the trend similarity measure, a set of time series presenting a progression similar to the current condition is identified in the historical dataset, which is then employed, through a nearest neighbor approach, in the current prediction. The strategy is evaluated using physiological data resulting from the myHeart telemonitoring study, namely blood pressure, respiration rate, heart rate, and body weight collected from 41 patients (15 decompensation events and 26 normal conditions). The obtained results suggest, in general, that the physiological data have predictive value, and in particular, that the proposed scheme is particularly appropriate to address the early detection of HF decompensation.

Challenges in rheumatic valvular disease: Surgical strategies for mitral valve preservation.

Abstract: In developing countries, rheumatic fever and carditis still constitutes a major public health problem. Patients have special characteristics that differ from those with rheumatic mitral valve disease we still see in developed countries. They are usually young, poor, uneducated, and have low compliance to prophylaxis / therapy. In addition, they usually have great difficulty in accessing medical care. In these situations, the rate of complications associated to valve replacement is significantly increased. Alternatively, mitral valve repair is now known to achieve better long-term results in this pathology, but this was not widely recognized three or four decades ago, when first reports showed worse results after repair of rheumatic regurgitation than with degenerative valves. This has been reported by several groups in developing countries in different continents, with high incidence of repairs and excellent long term results. It is, therefore, becoming increasingly clear that, although, the results may not compare to those obtained with degenerative pathology, repair of rheumatic valves, when feasible, is the procedure of choice, especially in these underprivileged populations.

Negative impact of atrial fibrillation and pulmonary hypertension after mitral valve surgery in asymptomatic patients with severe mitral regurgitation: a 20-year follow-up

Abstract: OBJECTIVES The timing for mitral valve (MV) surgery in asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular (LV) function remains controversial. We aimed at analysing the long-term outcome of asymptomatic patients with atrial fibrillation (AF) and/or pulmonary hypertension (PHT) after successful MV repair. METHODS From January 1992 to December 2012, 382 patients with severe degenerative MR, with no or mild symptoms, preserved LV function (ejection fraction > 60%) and LV systolic dimensions <45 mm were submitted to surgery and followed up for up to 22 years (3209 patient-years). Patients with associated surgeries, other than tricuspid repair, were excluded. Patients with AF and/or PHT (Group A; n = 106, 24.4%) were compared with patients without these comorbidities (Group B; n = 276, 63.6%). Propensity-score matching (for preoperative variables) was performed obtaining 102 patients in each arm. Survival and event-free survival [major cardiac and cerebrovascular events (MACCEs); freedom from mitral reoperation and recurrent moderate and severe MR] were analysed. RESULTS MV repair was performed in 98.2% of cases and tricuspid annuloplasty in 6.9%. Overall 30-day mortality was 0.8%, not different between groups, and absent in patients with isolated posterior leaflet prolapse (n = 211). Patients with AF/PHT had worse late survival by comparison with Group B patients (67.0 ± 7.4 vs 86.5 ± 3.9% at 15 years, P < 0.001), survival free from MACCE (52.7 ± 8.7 vs 74.5 ± 5.0%, P < 0.001), from recurrent moderate and severe MR (65.1 ± 10.3 vs 87.0 ± 3.8%, P = 0.002) and from mitral reoperation during the follow-up (87.3 ± 6.3 vs 94.2 ± 2.7%, P = 0.04). These differences were confirmed in the propensity score-matched population. Patients from Group A also displayed a lesser degree of reverse remodelling. There was a significant reduction in the systolic pulmonary artery pressure (SPAP) after surgery, more pronounced in Group A patients; nonetheless, the mean SPAP at late follow-up was higher in these patients (45 vs 30 mmHg). CONCLUSIONS MV repair can be achieved in the great majority of patients with degenerative regurgitation, with low mortality (<1%). Asymptomatic or mildly symptomatic patients with severe MR, preserved LV function and AF/PHT had poorer long-term survival and event-free survival even after a successful surgery. The durability of MV repair was also compromised in these patients, which indicates that they should have been operated earlier.

Preservation of the subvalvular apparatus during mitral valve replacement of rheumatic valves does not affect long-term survival.

Abstract: OBJECTIVES The importance of preservation of the subvalvular apparatus (PSVA) during mitral valve replacement (MVR) in non-rheumatic mitral valves is well recognized. Our aim was to analyse the impact of PSVA in MVR for rheumatic valves on long-term survival. METHODS From January 1992 to December 2012, 605 consecutive patients with rheumatic mitral valve disease were submitted to MVR. PSVA (limited to the posterior leaflet) was achieved in 224 (37.7%) patients. Follow-up was 4259 patient-years, and complete for 97% of the patients. Propensity score analysis was introduced to reduce selection bias. RESULTS Patients with PSVA were slightly older (61.9 vs 59.8 years, P = 0.014), with lower incidence of calcification (54.9 vs 63.0%, P = 0.05), pure mitral stenosis (29.9 vs 38.9%, P = 0.014) and history of rheumatic fever (44.6 vs 53.9%, P = 0.028). Mechanical prostheses were more frequently implanted in the Non-PSVA group (75.1 vs 65.6%, P = 0.013). Thirty-day mortality was 1.1%. Late survival rates at 5, 10 and 18 years were 86.6 ± 2.0, 70.8 ± 3.2 and 48.0 ± 5.1%, respectively, with no difference between groups. Both groups had compromised late survival when compared with the general population (age and gender matched, P < 0.001). Only age, large left atrium, pulmonary hypertension and 'pure' MR appeared as independent predictors for late mortality. There was no difference regarding adverse valve-related events between groups. CONCLUSIONS Patients submitted to MVR for rheumatic mitral valve disease have a poor prognosis, independently of having the subvalvular apparatus preserved. PSVA did not improve late survival in this setting.

Surgical Treatment of Posterior Mitral Valve Prolapse: Towards 100% Repair

Abstract: BACKGROUND The study aim was to evaluate the immediate and long-term results of surgical treatment of isolated posterior mitral valve leaflet prolapse (PLP), focusing on survival and freedom from recurrent mitral regurgitation (MR). METHODS Between January 1998 and December 2012, a total of 492 consecutive patients (375 males, 117 females; mean age 61.8 ± 12.1 years; range: 13-86 years) with isolated PLP [304 (61.8%) with myxomatous degeneration; 188 (38.2%) with fibroelastic deficiency] were treated at the authors' institution. Of these patients, 202 (41.1%) were in NYHA class III-IV, and atrial fibrillation was present in 104 (21.1%). Mitral valve repair was achieved in 484 patients (98.4%), resection was performed in 419 (85.2%), and prosthetic ring annuloplasty was used in 436 (88.6%). Concomitant procedures were performed in 153 patients (31.1%), including tricuspid valve repair in 50 (10.2%), aortic valve surgery in 34 (6.9%), and coronary artery bypass grafting (CABG) in 64 (13%). RESULTS The hospital mortality rate was 0.2%, and the mean follow up was 7.1 ± 3.9 years. There were 71 late deaths (14.4%), and overall survival at five, 10 and 15 years was 91.7 ± 1.3%, 82.1 ± 2.3% and 64.7 ± 6.1%, respectively. There was no significant difference in long-term survival compared with the age- and gender-matched general population (p = 0.146). Multivariate Cox-proportional hazard analysis showed older age (HR 1.03 per annum), left ventricular dysfunction (HR 2.44), atrial fibrillation (HR 1.96), left ventricular end-diastolic dimension (HR 1.05 per mm) and non-use of prosthetic ring (HR 3.03) as significant predictors of late mortality. Recurrence of moderate or severe MR occurred in 31 patients, six of whom underwent mitral valve reoperation. Predictors of late recurrence of MR were fibroelastic deficiency (HR 2.38), mitral calcification (HR 5.26), posterior leaflet plication (HR 3.58), absence of complete ring annuloplasty (HR 3.84) and systolic pulmonary artery pressure at discharge (HR 1.10 per mmHg). Freedom from mitral valve reoperation at 15 years was 97.4 ± 1.1% CONCLUSIONS: Mitral valve repair in isolated PLP can be achieved in virtually all cases with a very low operative risk and a high durability of repair. Atrial fibrillation or large left ventricles are associated with a poor prognosis. Failure to use a complete ring annuloplasty carries a risk not only for the return of MR but also for survival.

Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible?

Abstract: OBJECTIVES: Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement). METHODS: From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed. RESULTS: The mean time to surgery after PMC was 6.9 ± 5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P< 0.05). There was no hospital mortality. MV area increased on average 1.6 cm 2 after surgery to 2.7 cm 2 ; 5-, 10- and 20-year survival rates were 98.1 ± 1.9, 91 ± 5.2 and 82.7 ± 9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8 ± 4.1 and 87.8 ± 8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up. CONCLUSION: The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved.

Porcine or bovine: does it really matter?

Abstract: In a paper published in this issue of the European Journal of Cardio-thoracic Surgery, Hickey et al. [1] compare the performance of porcine and bovine pericardial valves implanted in the aortic position with respect to survival and intervention-free survival. This is a retrospective observational study of the National Institute for Cardiovascular Outcomes database on all first-time aortic valve replacements, with or without concomitant coronary artery bypass surgery, performed in England and Wales between April 2003 and March 2013. Approximately two thirds of the 38 040 patients included received a bovine pericardial prosthesis and the remainder had a porcine bioprosthesis implanted. The authors found no difference in survival up to 10 years of followup between the two groups of patients (49.0 and 50.3%, respectively). Similarly, there was no difference in intervention-free survival. Interestingly, however, the authors found ‘some evidence of a protective effect for porcine valves in relatively younger patients’. This work coincides in time with the decision of Edwards Lifesciences, one of the main manufacturers, and pioneer in the field, to discontinue their porcine models, which have been in use since the early 1970s. At that time, the bioprostheses were introduced with the objective of offsetting the thromboembolic complications of the mechanical valves, introduced one decade earlier. But the initial enthusiasm was soon dampened by early reports of biodegradation, especially in younger patients where they were hoped to be a better choice, by avoiding the need for use of anticoagulation [2]. Nonetheless, the bioprostheses remained a good option for older patients and for the last four decades were indicated for patients over 65–70 years of age by the guidelines on both sides of the Atlantic [3, 4]. Thus, the mechanical valves dominated the market and several models were implanted in millions of patients, exceeding 2 million in one model alone, with excellent performance records. But in the last decade, there has been a significant worldwide shift in surgeon’s attitude towards preferring bioprostheses, which are currently used in up to 80% of the patients, also justified by the increasing age of the population. On the other hand, the bovine pericardial valves were pioneered by Marian Ionescu [5] in England in 1976, but their use was only generalized in the 1980s and 1990s. They were initially implanted almost exclusively in the aortic position, and their main objective was the improvement of haemodynamic characteristics of the prosthesis, which were always perceived as less than perfect in the porcine models. In fact, most studies showed a better haemodynamic performance of the pericardial valves, with greater effective orifice areas and smaller gradients [6]. One issue that deserves special attention is the small aortic root requiring a small prosthesis, thought to be one of the Achilles’ heel of the bioprosthesis. Cases of patient–prosthesis mismatch were more common in the porcine valves. However, a negative impact of the mismatch, at least with respect to survival, has never been completely demonstrated, although faster and better resolution of the myocardial hypertrophy after valve replacement for aortic stenosis was observed in cases with no mismatch [7]. In fact, the series of Hickey et al. [1] showed similar reintervention-free survival in patients with small prostheses (≤21 mm), in whom gradient differences between these two valve types would be most marked. From this point of view, therefore, pericardial valves did not entirely match initial expectations. During their already long history, bioprostheses underwent important evolution and modifications aimed at both prolonging their durability and improving their haemodynamic performance. Several methods of treatment of the biological tissue were introduced, but there is no convincing evidence that any of those had significant impact on durability and freedom from calcification. Valve stents and assembling techniques were also modified and the dynamic properties were effectively ameliorated, thus bringing the porcine closer to the pericardial valves. Finally, there was the introduction of stentless bioprostheses, also with proven better haemodynamic properties, which have had an increasing acceptance, but they do not enter in this discussion. Then, why have the pericardial valves gained advantage over porcine prostheses? Having the above in mind, the decision by many surgeons to prefer pericardial valves was more emotionally based than scientifically proven, as appears to be consubstantiated by the conclusions of the work hereby discussed. It may be argued that there are many more models of bioprostheses than those utilized in this series, hence making generalization difficult, but the number of patients involved should offset these concerns. Interestingly, the two most used models of porcine and pericardial bioprostheses worldwide were also the most commonly used by the British surgeons and lowand moderate-volume surgeons had a greater propensity to use pericardial valves, which could also raise some questions. But there is one important limitation of the study of Hickey et al. [1]: the relatively short follow-up, with a mean of less than 4 years. When analysing the durability of bioprostheses, any follow-up shorter than 10 years must be viewed with some

Lowering pulmonary wedge pressure after heart transplant: pulmonary compliance and resistance effect.

Abstract: Background:Right ventricular (RV) afterload is an important risk factor for post-heart transplantation (HTx) mortality, and it results from the interaction between pulmonary vascular resistance (PVR) and pulmonary compliance (CPA). Their product, the RC time, is believed to be constant. An exception is observed in pulmonary hypertension because of elevated left ventricular (LV) filling pressures.Objective:Using HTx as a model for chronic lowering of LV filling pressures, our aim was to assess the variations in RV afterload components after transplantation.Methods:We retrospectively studied 159 patients with right heart catheterization before and after HTx. The effect of Htx on hemodynamic variables was assessed.Results:Most of the patients were male (76%), and the mean age was 53 ± 12 years. HTx had a significant effect on the hemodynamics, with normalization of the LV and RV filling pressures and a significant increase in cardiac output and heart rate (HR). The PVR decreased by 56% and CPA increased by 86%. The RC time did not change significantly, instead of increasing secondary to pulmonary wedge pressure (PWP) normalization after HTx as expected. The expected increase in RC time with PWP lowering was offset by the increase in HR (because of autonomic denervation of the heart). This effect was independent from the decrease of PWP.Conclusion:The RC time remained unchanged after HTx, notwithstanding the fact that pulmonary capillary wedge pressure significantly decreased. An increased HR may have an important effect on RC time and RV afterload. Studying these interactions may be of value to the assessment of HTx candidates and explaining early RV failure after HTx.

Loculated cardiac hematoma causing hemodynamic compromise after cardiac surgery.

Abstract: The authors describe a case of a rare complication occurring after cardiac surgery. Three weeks after aortic valve replacement a young male became hemodynamically unstable. The echocardiogram showed a large loculated hematoma compressing the right atrium. The patient was reoperated and the mass was removed. Recovery was complete.

Acoustic cardiac signal analysis: A toolbox

Abstract: We present a Matlab framework for heart sound processing and analysis. This framework includes algorithms developed for segmentation of the main heart sound components capable of handling situations with high-grade murmur, and for measuring systolic time intervals (STI). Methods for cardiac function parameter extraction based on STI are also included. Currently, the proposed algorithms are being extended for multi-channel applications. The algorithms outlined in the paper have been extensively evaluated using data collected from patients with several types of cardiovascular diseases under real-life conditions.

Detection of Atrial Fibrillation Using 12-Lead ECG for Mobile Applications

Abstract: Atrial Fibrillation (AF) is the most common arrhythmia and is associated with an increased risk of heart-related deaths and the development of conditions such as heart failure, dementia, and stroke. Affecting mostly elderly people, AF is associated with high comorbidity, increased mortality and is a major socio-economic impact in our society. Therefore, the detection of AF episodes in personalized health (p-Health) environments can be decisive in the prevention of major cardiac threats and in the reduction of health care costs. In this paper we present a new algorithm for detection of AF based on the assessment of the three main physiological characteristics of AF: (1) the irregularity of the heart rate; (2) the absence of the P-wave and (3) the presence of fibrillatory waves. Several features were extracted from the analysis of 12-lead electrocardiogram (ECG) signals, the best features were selected and a support vector machine classification model was adopted to discriminate AF and non-AF episodes. Our results show that the inclusion of features from the analysis of the recovered atrial activity was able to increase the performance of the algorithm: sensitivity of 88.5% and specificity of 92.9%. In the WELCOME project it is being designed a novel light vest with an integrated sensor system that collects several signals, including 12-lead ECG signals. The proposed algorithm is currently integrated in the WELCOME feature extraction module, which is responsible for receiving raw signals, extraction higher level features (e.g. occurrence of AF episodes) and provide them to the clinical decision process.

A economia e os custos das redes de referenciação de doentes para cirurgia cardíaca

Abstract: Num trabalho publicado nesta edição da revista1, os autores, do Serviço de Cardiologia de Faro, assumem o objetivo de comparar a sua experiência de referenciação de doentes para cirurgia cardíaca no período de 1/01/2008 a 30/09/2014, dividido em dois grupos, de 1/01/2008 a 01/08/2011 (43 meses; 557 doentes) e de 01/08/2011 a 30/09/2014 (37 meses; 307 doentes). Esta divisão temporal está relacionada com alterações das vias de referência emanadas das respetivas Administrações Regionais de Saúde. Tanto quanto se sabe, mas não está claramente explicitado no trabalho, os doentes eram referenciados preferencialmente para um determinado hospital de Lisboa durante o primeiro período e passaram a ser predominantemente enviados para outro no segundo. Por razões não explicadas, o número de doentes referenciados em cada um dos períodos não é proporcional à duração de cada um, mas é possível que tal se deva a alguma dispersão da rede de referência no período mais recente. As características demográficas e clínicas dos doentes dos dois grupos eram semelhantes, mas o tempo médio de espera para cirurgia passou de 10,6 ± 18,5 dias para 55,7 ± 79,9 dias, respetivamente, o que determinou uma diferença significativa da morbilidade, refletida em novos internamentos (0,4 e 9,1%), e da mortalidade (0 e 2,3%) durante a espera. Importa, no entanto, salientar que os tempos de espera nos

The economics and costs of patient referral protocols for cardiac surgery.

Abstract: The aim of the study in this issue of the Journal by Amado et al. of the Cardiology Department of Faro Hospital was to compare their experience of patient referrals for cardiac surgery between January 1, 2008 and September 30, 2014, divided into two groups: those referred between January 1, 2008 and August 1, 2011 (43 months; 557 patients) and those referred between August 1, 2011 and September 30, 2014 (37 months; 307 patients). The division into two time periods was prompted by changes to referral protocols issued by the Regional Health Authorities. Although it is not specifically stated in the article, it appears that patients were preferentially referred to a particular hospital in Lisbon during the first period and to a different one during the second period. For reasons that are not explained, the number of patients referred in each period is not proportional to the length of the period, but this may be due to a broadening of the referral network in the more recent period. The demographic and clinical characteristics of the two patient groups were similar but the mean waiting time increased from 10.6±18.5 days in the first period to 55.7±79.9 days in the second, which led to a significant difference in morbidity, as reflected in hospitalizations (0.4% and 9.1%, respectively) and mortality (0% and 2.3%) while