Decision support in surgical management of ischemic cardiomyopathy

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Presentation transcript:

Decision support in surgical management of ischemic cardiomyopathy Dustin Y. Yoon, MS, Nicholas G. Smedira, MD, Edward R. Nowicki, MD, MS, Katherine J. Hoercher, RN, Jeevanantham Rajeswaran, MSc, Eugene H. Blackstone, MD, Bruce W. Lytle, MD The Journal of Thoracic and Cardiovascular Surgery Volume 139, Issue 2, Pages 283-293.e7 (February 2010) DOI: 10.1016/j.jtcvs.2009.08.055 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Decision-support schema. I, Therapies applicable for ischemic cardiomyopathy. II, Survival comparisons of only applicable surgical therapies in the decision-support model. EF, Ejection fraction; MI, myocardial infarction; CABG, coronary artery bypass grafting; MVA, mitral valve anuloplasty; SVR, surgical ventricular restoration; LCTx, listing for cardiac transplantation; MR, mitral regurgitation; LVEDD, left ventricular end-diastolic diameter. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Time-related mortality after surgical therapies for ischemic cardiomyopathy. Each symbol represents a death positioned on a vertical axis by using a Kaplan–Meier estimator, and vertical bars represent 68% confidence limits equivalent to ±1 standard error. Solid lines are parametric survival estimates. CABG, Coronary artery bypass grafting; SVR, surgical ventricular restoration; LCTx, listing for cardiac transplantation; MVA, mitral valve anuloplasty. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Percentage (and number of patients for each bar) of patients predicted to have the highest 5-year survival after therapy received (upward-pointing bars) and those of patients predicted to have better 5-year survival with an alternative therapy (downward-pointing bars) for each therapy received. CABG, Coronary artery bypass grafting; MVA, mitral valve anuloplasty; SVR, surgical ventricular restoration; LCTx, listing for cardiac transplantation. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Survival predicted after each of 4 therapies for 4 different scenarios (see Table E5 for details). Top left, Scenario A; top right, scenario B; bottom left, scenario C; bottom right, scenario D. Dashed lines represent artificial survival curves for therapies not deemed applicable for the given patient's characteristics. LCTx, Listing for cardiac transplantation; CABG, coronary artery bypass grafting; SVR, surgical ventricular restoration; MVA, mitral valve anuloplasty. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Java-based user interface for clinical strategic decision support. Results for scenario A in Figure 4 are shown. CABG, Coronary artery bypass grafting; MVA, mitral valve anuloplasty; SVR, surgical ventricular restoration; LCTx, listing for cardiac transplantation. Used by permission of Cleveland Clinic. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Instantaneous risk of death (hazard function after each surgical therapy for ischemic cardiomyopathy). A, Risk of death to 9 years. B, Risk of death within first year. Solid lines are parametric estimates. CABG, Coronary artery bypass grafting; SVR, surgical ventricular restoration; MVA, mitral valve anuloplasty; LCTx, listing for cardiac transplantation. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Graphic comparisons of model validation for each therapy Graphic comparisons of model validation for each therapy. Solid lines enclosed within dashed 68% confidence limits are predicted survival estimates, symbols and vertical 68% confidence bars are Kaplan–Meier estimates of actual survival in the 20% holdout samples, and numbers in parentheses represent patients remaining at risk. Dots are Brier scores at each event time point, with the 0.25 line as the reference value below which predicted and observed survival are deemed appropriate. CABG, Coronary artery bypass grafting; SVR, surgical ventricular restoration; MVA, mitral valve anuloplasty; LCTx, listing for cardiac transplantation. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Cumulative 5-year survival difference between therapy received and therapy maximizing survival. Differences were calculated only for patients for whom an alternative therapy to the one received was predicted to provide greater 5-year survival. CABG, Coronary artery bypass grafting; SVR, surgical ventricular restoration; MVA, mitral valve anuloplasty; LCTx, listing for cardiac transplantation. The Journal of Thoracic and Cardiovascular Surgery 2010 139, 283-293.e7DOI: (10.1016/j.jtcvs.2009.08.055) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions