St. Paul's Hospital is an acute care hospital located in downtown Vancouver, British Columbia, Canada. It is the oldest of the seven health care facilities operated by Providence Health Care, a Roman Catholic faith-based care provider.St. Paul's is open to patients regardless of their faith and is home to many medical and surgical programs, including cardiac services and kidney care including an advanced structural heart disease program and North America's largest Addiction Fellowship program. It is also the home of the Pacific Adult Congenital Heart Disease unit. It is one of the teaching hospitals of the University of British Columbia Faculty of Medicine. Approximately 4000 people work at St Paul's Hospital.On August 12, 2020, it was announced that the hospital's land in downtown Vancouver was sold to Concord Pacific for nearly $1 billion. Providence Health Care, the hospital operator, mentioned that the proceeds from this sale would go to the construction of the new St. Paul's Hospital in the False Creek Flats neighborhood, which is expected to open in 2027.St.
Since the first-in-human procedure in 2002, transcatheter aortic valve implantation (TAVI) has become a well-established therapeutic option for severe aortic stenosis, and is offered increasingly to patients at lower surgical risk, who are typically younger. Increasing lifespan carries concerns that "minor" complications that may have little impact in elderly patients could have a greater long-term impact in younger patients. Issues such as mild paravalvular regurgitation, hypoattenuated leaflet thickening, atrioventricular block with need for permanent pacemaker implantation or future coronary access may have a substantial cumulative undesirable impact. Additionally, as with surgical bioprosthetic valves, transcatheter bioprosthetic valves will eventually degenerate, and may require repeat intervention. Although durability data for transcatheter heart valves (THVs) is encouraging, very late data are lacking. Redo TAVI has been shown to be feasible with acceptable outcomes in patients with failed THVs, but in some patients, anatomical or device considerations may preclude a repeatable procedure because of the risk of coronary obstruction. Various strategies for lifetime management in this lower-risk and younger population have been proposed: surgical aortic valve replacement (SAVR) first, followed by TAVI; TAVI then SAVR; TAVI then TAVI, etc. A tailored approach may be considered according to patient co-morbidities, anatomy and the relative advantages and disadvantages of the two therapies. This review offers an overview of current challenges when considering TAVI in populations at lower risk, and summarizes the different approaches that have been developed to address these concerns.
IMPORTANCE Transcatheter aortic valve replacement (TAVR) failure is often managed by an urgent implantation of a supplementary valve during the procedure (2-valve TAVR [2V-TAVR]). Little is known about the factors associated with or sequelae of 2V-TAVR. OBJECTIVE To examine the incidence, causes, and outcomes of 2V-TAVR. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was performed using data from an international registry of 21 298 TAVR procedures performed from January 1, 2014, through February 28, 2019. Among the 21 298 patients undergoing TAVR, 223 patients (1.0%) undergoing 2V-TAVR were identified. Patient-level data were available for all the patients undergoing 2V-TAVR and for 12 052 patients (56.6%) undergoing 1V-TAVR. After excluding patients with missing 30-day follow-up or data inconsistencies, 213 2V-TAVR and 10 010 1V-TAVR patients were studied. The 2V-TAVR patients were compared against control TAVR patients undergoing a 1-valve TAVR (1V-TAVR) using 1:4 17 propensity score matching. Final analysis included 1065 (213:852) patients. EXPOSURES Urgent implantation of a supplementary valve during TAVR. MAIN OUTCOMES AND MEASURES Mortality at 30 days and 1 year. RESULTS The 213 patients undergoing 2V-TAVR had similar age (mean [SD], 81.3 [0.5] years) and sex (110 [51.6%] female) as the 10 010 patients undergoing 1V-TAVR (mean [SD] age, 81.2 [0.5] years; 110 [51.6%] female). The 2V-TAVR incidence decreased from 2.9% in 2014 to 1.0% in 2018 and was similar between repositionable and nonrepositionable valves. Bicuspid aortic valve (odds ratio [OR], 2.20; 95% CI, 1.17-4.15; P = .02), aortic regurgitation of moderate or greater severity (OR, 2.02; 95% CI, 1.49-2.73; P < .001), atrial fibrillation (OR, 1.43; 95% CI, 1.07-1.93; P = .02), alternative access (OR, 2.59; 95% CI, 1.72-3.89; P < .001), early-generation valve (OR, 2.32; 95% CI, 1.69-3.19; P < .001), and self-expandable valve (OR, 1.69; 95% CI, 1.17-2.43; P = .004) were associated with higher 2V-TAVR risk. In 165 patients (80%), the supplementary valve was implanted because of residual aortic regurgitation after primary valve malposition (94 [46.4%] too high and 71 [34.2%] too low). In the matched 2V-TAVR vs 1V-TAVR cohorts, the rate of device success was 147 (70.4%) vs 783 (92.2%) (P < .001), the rate of coronary obstruction was 5 (2.3%) vs 3 (0.4%) (P = .10), stroke rate was 9 (4.6%) vs 13 (1.6%) (P = .09), major bleeding rates were 25 (11.8%) vs 46 (5.5%) (P = .03) and annular rupture rate was 7 (3.3%) vs 3 (0.4%) (P = .03). The hazard ratios for mortality were 2.58 (95% CI, 1.04-6.45; P = .04) at 30 days, 1.45 (95% CI, 0.84-2.51; P = .18) at 1 year, and 1.20 (95% CI, 0.77-1.88; P = .42) at 2 years. Nontransfemoral access and certain periprocedural complications were independently associated with higher risk of death 1 year after 2V-TAVR. CONCLUSIONS AND RELEVANCE In this cohort study, valve malposition was the most common indication for 2V-TAVR. Incidence decreased over time and was low overall, although patients with a bicuspid or regurgitant aortic valve, nontransfemoral access, and early-generation or self-expandable valve were at higher risk. These findings suggest that compared with 1V-TAVR, 2V-TAVR is associated with high burden of complications and mortality at 30 days but not at 1 year.
Defibrillation threshold (DFT) testing has traditionally been a routine part of implantable cardioverter-defibrillator (ICD) implantation, despite a lack of compelling evidence that it predicts or improves outcomes. In the past, when devices were much less reliable, DFT testing seemed prudent; however, modern ICD systems have such a high rate of successful defibrillation that many electrophysiologists now question whether DFT testing is still worthwhile, particularly since DFT testing may now be the highest acute risk component of ICD implantation.The purpose of this study was to systematically document complications directly attributable to intraoperative DFT testing.We obtained data on DFT-related complications from all 21 adult ICD implant centers in Canada, covering the period from January 1, 2000, to September 30, 2006.There were a total of 19,067 ICD implants in Canada during the study period. There were three DFT testing-related deaths, five DFT testing-related strokes, and 27 episodes that required prolonged resuscitation. Two patients had significant clinical sequelae after prolonged resuscitation.The risk of severe complications from intraoperative DFT testing appears small, even allowing for the underestimation of its true rate with the current study methodology. These slight but measurable risks must be considered when assessing the risk-benefit ratio of the procedure. Additional data from ongoing prospective ICD registries and/or clinical trials are required.
Le ministère de la Santé de la Colombie-Britannique a fermé un hôpital de soins aigus en 1993. On a mené une étude sur les façons dont cette fermeture a touché les employés de l'hôpital pour déterminer des moyens de faciliter le processus de fermeture et de réorganisation. On a interviewé en privé 25 employés au moment de la fermeture et six mois plus tard. Six thèmes se sont dégagés de l'analyse qualitative dans la catégorie « vivre la fermeture ». Ces thèmes sont: (1) la communication de l'information, (2) l'effet de la fermeture sur le milieu de travail et sur les collègues, (3) le stress perçu, (4) la reconnaissance de sa propre valeur, (5) la prestation de services de soutien et (6) le processus d'avoir un nouvel emploi. Les auteurs off rent des recommandations émanant de cette analyse pour aider d'autres person nes à planilier les futures réorganisations ou fermetures d'hôpitaux.
