The Effect of Depth of Anaesthesia on the Severity of Mitral Insufficiency by Transesophageal Echocardiography

Background The assessment of mitral regurgitation (MR) is complex and complicated by the dynamic nature of this valvular abnormality. Intraoperative transesophageal echocardiography (TEE) is a well-established tool that is used to assess the mitral regurgitation (MR) before and after mitral valve reconstruction. Objectives This study conducted in the National Heart Institute in Cairo aimed at assessing the effect of depth of anaesthesia guided by bispectral index on the severity of mitral insufficiency as measured by transesophageal echocardiography. Patients and Methods This study was conducted in the National Heart Institute in Cairo. The study was conducted for a period of about six months after the approval from Ethical committee. Informed oral consent for every patient was obtained. Prospective observational cross-sectional study with a random sample of 20 patients at National Heart Institute. A sample size of at least 15 data pairs achieves 80% power to reject the null hypothesis of zero effect size when the population effect size is 0.80 and the significance level (alpha) is 0.05 using a two-sided paired ttest. Adult patients undergoing elective cardiac surgery in National Heart Institute. Results The MR severity decreased at a deeper anaesthesia at low BIS than at a shallower anaesthesia at high BIS in patients with organic MR. Eight patients out of twenty patients (40% with organic MR) showed a + 1 grade of improvement in MR grade, by semi-quantitively measuring maximal JA and VC width. Improvement in mitral regurge severity thought to be secondary to unloading effect of general anaesthesia on left ventricle causing a decrease in afterload, preload, and left ventricular dimensions. This study demonstrated that, a comparison between deep anaesthesia and shallow anaesthesia using BIS showed there is a significant reduction in multiple parameters of MR severity assessment secondary to unloading effect of general anaesthesia on left ventricle caused by a decrease in both afterload and preload. Conclusion This reduction in MR severity appeared to be significant enough to modify intraoperative decisions regarding valve surgery by underestimation of valve severity. Thus, strong consideration should be given to thorough preoperative assessment of MR severity, rather than relying on intraoperative findings.

Establishment of a cardiac telehealth program to support cardiovascular diagnosis and care in a remote, resource-poor setting in Uganda

Introduction To address workforce shortages and expand access to care, we developed a telemedicine program incorporating existing infrastructure for delivery of cardiovascular care in Gulu, Northern Uganda. Our study had three objectives: 1) assess feasibility and clinical impact 2) evaluate patient/parent satisfaction and 3) estimate costs. Methods All cardiology clinic visits during a two-year study period were included. All patients received an electrocardiogram and echocardiogram performed by a local nurse in Gulu which were stored and transmitted to the Uganda Heart Institute in the capital of Kampala for remote consultation by a cardiologist. Results were relayed to patients/families following cardiologist interpretation. The following telemedicine process was utilized: 1) clinical intake by nurse in Gulu; 2) ECG and echocardiography acquisition in Gulu; 3) echocardiography transmission to the Uganda Heart Institute in Kampala, Uganda; 4) remote telemedicine consultation by cardiologists in Kampala; and 5) communication of results to patients/families in Gulu. Clinical care and technical aspects were tracked. Diagnoses and recommendations were analyzed by age groups (0–5 years, 6–21 years, 22–50 years and > 50 years). A mixed methods approach involving interviews and surveys was used to assess patient satisfaction. Healthcare sector costs of telemedicine-based cardiovascular care were estimated using time-driven activity-based costing. Results Normal studies made up 47%, 55%, 76% and 45% of 1,324 patients in the four age groups from youngest to oldest. Valvular heart disease (predominantly rheumatic heart disease) was the most common diagnosis in the older three age groups. Medications were prescribed to 31%, 31%, 24%, and 48% of patients in the four age groups. The median time for consultation was 7 days. A thematic analysis of focus group transcripts displayed an overall acceptance and appreciation for telemedicine, citing cost- and time-saving benefits. The cost of telemedicine was $29.48/visit. Conclusions Our data show that transmission and interpretation of echocardiograms from a remote clinic in northern Uganda is feasible, serves a population with a high burden of heart disease, has a significant impact on patient care, is favorably received by patients, and can be delivered at low cost. Further study is needed to better assess the impact relative to existing standards of care and cost effectiveness.

Evaluation of patient satisfaction and the service quality of the outpatient care at the Heart Institute of Ho Chi Minh City

Background and aims: This study assesses the levels and determinants of patient satisfaction with outpatient care at the Heart Institute of Ho Chi Minh City in 2018. Methods: A cross-sectional descriptive survey was carried among 401 randomly selected outpatients at the Heart Institute of Ho Chi Minh City from June to November 2018. The data were collected on pre-designed and pre-tested questionnaire that contained 32 items. The survey examined four main aspects of the service quality: “the accessibility of healthcare services”, “the transparency of information and procedures”, “the quality of the medical infrastructure and facilities”, “the behavior and professional competence of medical and service staff”. The survey asked the patients to evaluate the outcome of service delivery and satisfaction based on the 5 levels Linkert scale. Descriptive statistics, factor analysis and multiple linear regressions were performed to test the hypothesized relationships between service quality and patient satisfaction with the outpatient care. Results: Satisfaction of patients and relatives of patients about the quality of outpatient care was high, reaching the average 87.3 percent of patients’ expectation with the minimum of 50 to 100. 30% patients were not satisfied towards the booking appointments via phone, and online services. 35% patients were not happy with the long times waiting to get the registration, to see the doctors, to do the investigations and receive the results, and 54.1% respondents were not happy with toilet and drinking water facilities. Three dimensions of service quality significantly impacted the patient satisfaction and the outcome of service delivery: “the transparency of the information”, “the behavior and competence of medical staff and service staff”, and “the quality of the medical infrastructure and facilities”. The level of satisfaction was not statistically different among patient’s characteristics at p