Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Ann Thorac Surg. 2021 Aug;112(2):582-588. doi: 10.1016/j.athoracsur.2020.09.014. Epub 2020 Oct 27.
This study evaluated our institutional experience in forming a surgeon-based committee to discuss and provide consensus opinion on high-risk cardiac surgical cases.
The committee consisted of 4 surgeons with at least 1 senior surgeon at any given time with a rotating schedule. Patients with a Society of Thoracic Surgeons predicted risk of mortality above specified thresholds were mandated for referral to the committee in addition to patients referred at the discretion of the surgeon. Kaplan-Meier analysis was used to model survival.
A total of 110 consecutive patients were reviewed by the committee. The most common procedure types for referral were isolated coronary artery bypass grafting (47.3%; n = 52) and coronary artery bypass grafting with concomitant aortic valve replacement (19.1%; n = 21). The overall median Society of Thoracic Surgeons predicted risk of mortality for referred patients was 5.35% (interquartile range, 4.07%-7.89%). After group discussion, a total of 62 patients were recommended to proceed with surgery (56.4%). Reasons for declining surgery included consensus that an intervention was not indicated (39.6%; n = 19), that an alternative, nonsurgical procedure was recommended (29.2%; n = 14), that there was continued medical management and reevaluation (18.8%; n = 9), and that the patient was deemed at too high a risk for surgery (12.5%; n = 6). Operative mortality in patients proceeding with surgery was 4.6% (n = 2), with an observed-to-expected mortality of 0.86. The 6-month survival after surgery was 92.2%.
Implementation of a surgeon-based committee to discuss high-risk cases provided a unified voice to referring physicians and facilitated consensus decision-making with acceptable clinical outcomes in a challenging patient cohort.
本研究评估了我们机构在组建一个以外科医生为基础的委员会来讨论和提供高危心脏手术病例的共识意见方面的经验。
该委员会由 4 名外科医生组成，任何时候至少有 1 名资深外科医生，并有轮流值班的安排。除了由外科医生自行决定转介的患者外，预测死亡率超过特定阈值的患者都必须转介给委员会。使用 Kaplan-Meier 分析来建模生存率。
共有 110 例连续患者接受了委员会的审查。转介的最常见手术类型是单纯冠状动脉旁路移植术（47.3%；n=52）和冠状动脉旁路移植术伴同期主动脉瓣置换术（19.1%；n=21）。转介患者的总体中位数胸外科医生协会预测死亡率为 5.35%（四分位距，4.07%-7.89%）。经过小组讨论，共有 62 例患者被推荐进行手术（56.4%）。拒绝手术的原因包括一致认为不需要干预（39.6%；n=19），推荐采用非手术治疗方法（29.2%；n=14），继续进行医学治疗和重新评估（18.8%；n=9），以及患者被认为手术风险过高（12.5%；n=6）。进行手术的患者的手术死亡率为 4.6%（n=2），观察到的死亡率为 0.86。手术后 6 个月的生存率为 92.2%。
实施以外科医生为基础的委员会来讨论高危病例，为转诊医生提供了一个统一的声音，并在具有挑战性的患者群体中通过可接受的临床结果促进了共识决策。
