José J. Cuenca Castillo

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO ( Indicadores de Calidad en Unidades Asistenciales del Área del Corazón ): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Quality markers in cardiology: measures of outcomes and clinical practice--a perspective of the Spanish Society of Cardiology and of Thoracic and Cardiovascular Surgery.

The complexity of the individual patient and organization of medical practice results in important institutional and country quality of care variability.1–17 Attempts to assess the quality of clinical practice have established rating systems that may yield completely different results and rating for the same hospital during the same period of time, adding confusion rather than help to prove their usefulness and, questioning whether existing measures can actually measure quality.18–35 Most important, benchmarking may be associated with progressive improvement both in performance and outcomes,18,26,28,36–38 highlighting the relevance of standardization of quality measures and the responsibility of scientific societies. The Spanish Society of Cardiology (SSC) and the Spanish Society of Thoracic and Cardiovascular Surgery (SSTCS) organized a task force to identify and define two sets of quality metrics in hospital cardiology practice: (i) outcome measures (metrics of the final quality of the practice of cardiology) and (ii) performance measures (metrics of clinical practice which are known to positively influence desirable outcomes). Beyond this objective, Scientific Societies and Health Care Authorities should be responsible for the implementation of programmes to measure quality, ensure the quality of the data, benchmarking, and certification/accreditation of cardiology services. All European Society of Cardiology (ESC)32 and American Heart Association/American College of Cardiology33 guidelines were reviewed and recommendations related to quality standards were included in the document. ### Grading of quality markers Three levels were established both for class recommendation and level of evidence considering (i) clinical and practical …

Tratamiento quirúrgico de la insuficiencia cardiaca. Restauración ventricular y cirugía de la válvula mitral

La eficiencia del corazon como bomba esta intimamente ligada a la estructura y la disposicion de sus fibras musculares. Debemos considerar el proceso de remodelado ventricular, tras un dano miocardico, como un elemento etiopatogenico de la insuficiencia cardiaca. En este contexto, el desarrollo de insuficiencia mitral functional dispara la sintomatologia del paciente y empeora su pronostico. En los ultimos anos se ha introducido el concepto de restauracion ventricular como una nueva aproximacion diagnostica y terapeutica en el paciente con insuficiencia cardiaca. La resonancia magnetica se ha convertido en la exploracion princeps para el diagnostico y el seguimiento de estos pacientes. Desde el punto de vista quirurgico debemos entender el abordaje de estos pacientes como una trilogia: hay que actuar sobre las arterias coronarias, reparar la valvula mitral si hay una insuficiencia al menos moderada, y realizar una reduccion del volumen ventricular.

Cirugía cardiovascular. Definición, organización, actividad, estándares y recomendaciones

Resumen La cirugia cardiovascular (CCV) es una especialidad de la medicina que se ocupa de los trastornos y enfermedades del sistema cardiocirculatorio que requieren una terapeutica quirurgica. El presente documento esta dedicado a los aspectos definitorios de la especialidad y a los organizativos de la actividad profesional incluyendo la acreditacion y homologacion. se define asimismo la sociedad profesional, la sociedad Espanola de Cirugia Toracica-Cardiovascular (SECTCV) en sus aspectos relacionados con la profesion, con la formacion continuada asi como la comunicacion en el seno y fuera de la misma al igual que la necesidad y existencia de la fundacion Cirugia y Corazon (FCC). Tambien se focaliza en la actividad en CCV y los requerimientos estructurales minimos para llevar a cabo el componente de intervencion de la CCV. Por ultimo, se confirman las recomendaciones para su practica y se presentan los requerimientos de calidad y del programa docente de la especialidad. Este documento de la junta directiva de la SECTCV y asesores externos de la misma confirma la realidad de la especialidad y sus contenidos como senas de identidad inalienables.

Comments on the ESC guidelines on the management of valvular heart disease (version 2012). A report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology.

A task force was formed consisting of experts from different fields. Members of the task force were proposed by the SEC Clinical Cardiology, Cardiac Catheterization, and Cardiac Imaging sections and by the SECTCV (Spanish Society of Thoracic and Cardiovascular Surgery). The Task Force was coordinated by 2 representatives of the CGPC. The guidelines were divided into blocks and sent to members of the Task Force, who analyzed the most novel and important aspects in terms of clinical practice. They also gave their opinion on the methodology used, possible areas of conflict, and limitations with regard to other guidelines. In addition, they were asked to describe the implications for actual practice in the Spanish setting. The information received was used to produce a first draft of the document, which the original committee evaluated before referring it to a second group of 11 reviewers also proposed by sections of the SEC and the SECTCV. All authors and reviewers were asked to disclose any conflicts of interest, details of which are provided at the end of the article.

Temas de actualidad en insuficiencia cardiaca

En el presente articulo se presentan los avances mas destacados en el campo de la insuficiencia cardiaca en el ultimo ano. Se exponen las principales novedades en el manejo de la insuficiencia cardiaca cronica tanto en los aspectos mas relevantes de los nuevos modelos de gestion del paciente con insuficiencia cardiaca cronica como en los avances farmacologicos y en el uso y la indicacion de dispositivos en estos pacientes. Tambien se revisan los nuevos adelantos en el abordaje de la insuficiencia cardiaca en su fase mas avanzada, con especial enfasis en la fase aguda. Los nuevos enfoques del manejo quirurgico de la insuficiencia cardiaca, incluyendo en este apartado las nuevas aportaciones en el campo de las asistencias circulatorias, merecen un papel destacado en esta actualizacion.

El volumen telesistólico del ventrículo izquierdo es la clave para la indicación y el éxito de la restauración ventricular quirúrgica

El estudio Surgical Treatment for Ischemic Heart Failure (STICH), publicado en The New England Journal of Medicine en marzo de 20091, comparó la reducción ventricular quirúrgica asociada a derivación coronaria frente a derivación coronaria aislada, concluyendo que la reducción del volumen ventricular izquierdo no mejora la supervivencia, los síntomas, la capacidad de ejercicio, ni disminuye los reingresos por causa cardíaca. Sin embargo, numerosos autores con gran experiencia en las técnicas de restauración ventricular y en el seguimiento de estos pacientes han señalado diversas características del diseño del estudio, que hacen sus conclusiones limitadas a un determinado grupo de pacientes, y limitaciones en la aplicación de la técnica quirúrgica, que podría limitar sus beneficios. La principal crítica vertida al estudio es que la reducción ventricular tras la cirugía, en el grupo de restauración ventricular, ha sido tan sólo del 19% de media, dejando todavía un ventrículo izquierdo demasiado grande. Los datos publicados el pasado mes de febrero, por Di Donato, et al. (Universidad de Florencia, Italia) en nombre del grupo con más experiencia mundial en el manejo de estos pacientes, han hecho hincapié en la importancia del volumen telesistólico ventricular izquierdo (VTSVI) postoperatorio en la supervivencia de los pacientes2. En el estudio realizado sobre 216 pacientes consecutivos en los que se realizó reconstrucción ventricular izquierda, se consiguió una reducción media del 41% del VTSVI. Se concluyen aspectos importantes que podemos resumir: Cir. Cardiov. 2010;17(1):37-9

Perceval Less Invasive Aortic Replacement Register: multicentric Spanish experience with the Perceval S bioprosthesis in moderate–high-risk aortic surgery

OBJECTIVES The development of new percutaneous and surgical techniques has reduced the risk associated with aortic valve replacement procedures. We present the results of a Spanish register after initiating a programme for sutureless prostheses in moderate-high-risk patients. METHODS This prospective multicentre study was carried out from November 2013 to November 2016. Data were obtained from 448 patients in whom a Perceval S prosthesis was implanted. RESULTS The mean age was 79.24 (standard deviation [SD] 4.1) years, and 61.2% were women. The estimated EuroSCORE I log risk was 11.15% (SD 7.6), with an observed mortality of 4.4% (20 patients). Isolated aortic valve replacement was performed on 69.26% of patients, with 64% involving ministernotomy. The incidence of neurological events was 2%, with 2 permanent cerebrovascular accidents, and 41 (9.2%) patients were implanted with a permanent endocavitary pacemaker. At discharge, 12 (2.6%) patients presented minimal periprosthetic leakage, and 4 (0.89%) patients had moderate leakage. There were 3 reinterventions during follow-up (2 endocarditis and 1 dysfunction due to periprosthetic leak progression). The mean gradient at discharge, 6 months and 1 year was 12.94 (SD 5.3) mmHg, 12.19 (SD 4.7) mmHg and 11.77 (SD 4.7) mmHg, respectively; 59.4% of the patients were octogenarians, with a survival rate of 98% at both 6 months and 1 year at discharge. There was neither valve migration nor early structural degeneration. The mean follow-up was 12 ± 3 months. The 6-month and 1-year mortality was 1.4% and 2.1%, respectively. CONCLUSIONS This is a prospective multicentric study on the largest cohort of patients with sutureless valves conducted in Spain to date. It is a reproducible procedure that has enabled surgery on patients with a moderate-high risk with low morbidity and mortality, providing good haemodynamic results.

Beating Heart Coronary Artery Surgery

This book has two important qualities that make it worthy of a place in any cardiological library. On the one hand, it is the first book to compile detailed new technical information about coronary surgery on the heart in movement. On the other, it has been edited by one of the most active pioneering groups in this technique in the United States. Moreover, the most experienced surgeons in this field in the world have contributed as authors of the different chapters of this book. The text is organized into four sections. The first, single-chapter section is dedicated to a historical review of the problem. The second section consists of eight purely technical chapters on innovative and salient aspects of coronary surgery without extracorporeal circulation. The reader, with the sufficient (but not brilliant) aid of the illustrations can obtain a clear idea about the principles of the exposure and stabilization of the coronary arteries, hemodynamic management of the patient, and verification of anastomotic patency. The third section dedicates six chapters to analyzing different approaches to surgery on the beating heart in order to select the one most suitable for each patient. The last section, as could be expected, consists of seven chapters that analyze the overall results and complications of this technique and subgroups like highrisk patients and the elderly. The results are presented, for the most part, in tables that compare «beating heart» surgery to conventional surgery with extracorporeal circulation as a way of analyzing its benefits.