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Journal and News Scan
Controversial and revisited topic of dual-antiplatelet therapy (DAPT) (aspirin and clopidogrel) versus low dose warfarin after On-X mechanical aortic valve replacement. There were two arms to the study: low and high risk for thromboembolism. The low-risk arm was terminated secondary to higher thromboembolic events in the DAPT group. For the high-risk groups, patients receiving low dose warfarin with an international normalized ratio goal of 1.5 to 2.0 experienced no difference in mortality or thromboembolic complications compared to the standard dose warfarin group.
Patient Care and General Interest
Cardiac arrest survivors gathered at Basildon Hospital in the UK to share their stories and raise awareness, while attempting to set a world record for most cardiac arrest survivors at one gathering.
The University of Washington in the US joins a growing list of institutions that offer hearts from hepatitis C-positive donors to patients on the transplant waiting list, as evidence accumulates that the virus can be safely treated in organ recipients.
Drugs and Devices
Japan’s Ministry of Health, Labor, and Welfare has approved the Perceval sutureless valve from LivaNova for treating aortic valve disease.
Research, Trials, and Funding
Researchers from the University of California Los Angeles in the US and from Edwards Lifesciences trained a machine-learning algorithm to predict intraoperative hypotension using physiological data that is routinely collected during surgery.
Swedish researchers have found an association between invasive procedures such as coronary artery bypass grafting and infective endocarditis, and the accompanying editorial postulated that improving sterile technique and procedures for infection control when possible may prove more beneficial than administering prophylactic antibiotics.
Research presented at the recent American Thoracic Society meeting in San Diego, California, evaluated patient refusal of lung cancer treatment, finding that US patients with early stage disease were more likely to refuse surgical treatment if they did not have insurance or if they were covered by Medicaid.
Semenkovich and colleagues examined the current treatment practices for empyema in New York state using information from the Healthcare Cost and Utilization Project New York State Inpatient Database. The largest proportion of patients were initially treated with chest tube placement (38.2%) rather than a VATS or open surgical approach, and only 53% of patients were treated with a single procedure, highlighting that definitive treatment was often not the first treatment given. When patients were stratified by definitive treatment, the reintervention rate was higher for patients who treated with a chest tube than for patients treated by either surgical approach (6.1% versus 1.9% and 2.1%).
Antonides and colleagues present fundamental concepts of cost–effectiveness analysis (CEA) and they discuss the interpretation of these analyses. CEAs of new treatment strategies are being increasingly reported in the literature and national reports, and governments and healthcare payers frequently require a CEA to aid in the decision of whether to fund a new treatment or not. The authors consider a real-world example CEA, comparing transcatheter to surgical aortic valve replacement for intermediate-risk patients.
Size-based parameters have both value and limitations in predicting the risk of aortopathy in patients with bicuspid aortic valves. Given the limitations of these morphological predictive tools, Naito and colleagues review the potential of biomarkers to assess aortic disease in these patients. The authors discuss evidence for markers that are more routinely available for testing, such as MMPs, TIMPs, and alpha 1-antitrypsin, as well as those markers that are primarily experimental.
Patient Care and General Interest
A charity bazaar raised money for a Shanghai Chest Hospital project that offers free heart surgery to children with congenital heart disease in China.
Trillium Health Partners and Saint Elizabeth Health Care in Ontario, Canada, have been recognized with the Canadian College of Health Care Leader’s 3M Health Care Quality Team Award for their Putting Patients at the Heart Program, which focuses on postoperative care for cardiac patients.
Drugs and Devices
AtriCure and Baheal Pharmaceutical Group have agreed to a partnership for the latter to distribute AtriCure’s surgical ablation devices in China.
Research, Trials, and Funding
Survival after congenital heart surgery is improving; however, researchers from Minnesota, USA, find that mortality for this group of patients remains higher than in the general population, even for relatively mild structural defects.
Researchers from Ontario, Canada, find lower survival and higher likelihood of readmission for heart failure in patients who required a permanent pacemaker after transcatheter aortic valve replacement compared to patients who did not need a pacemaker.
Analysis of the Framingham Heart Study cohorts suggests that quitting smoking substantially lowers lung cancer risk, even within five years of quitting, although the risk for former smokers remains higher than for never-smokers.
Johnston and colleagues evaluated morbidity and mortality following different cardiac operations at 18 institutions to determine if outcomes of coronary artery bypass grafting (CABG), aortic valve replacement, and mitral valve replacement were correlated within each institution. The large volume of CABG makes this procedure an obvious choice for large-scale measurement and reporting of outcomes, and the authors sought to determine if CABG outcomes correlated with, and could therefore be considered representative of, valve replacement outcomes. While the institutional observed-to-expected (OE) ratios for mortality were not correlated across the three procedures, the OE ratios for morbidity were. The authors suggest this could reflect greater dependence of morbidity on postoperative care and resources that are more broadly shared within an institution and greater dependence of early mortality on procedure-specific skills.
Dobrovie and colleagues performed a retrospective analysis of mitral regurgitation (MR) in 128 patients who had a left ventricular assist device (LVAD) implanted. The authors found that even severe MR improved following LVAD implantation without intraoperative repair of the valve. Survival after one and three years for patients with severe preoperative MR was comparable to LVAD patients with none to moderate preoperative MR.
Timman and colleagues assessed the functional outcomes of patients who underwent laryngotracheal resection (LTR) and reconstruction for benign laryngotracheal stenosis. Between 1996 and 2017, 119 consecutive patients underwent LTR (n = 47) or end-to-end segmented tracheal resection (n = 56). There was consistent functional improvement during follow-up, particularly with respect to the sensation of dyspnea during exercise and the reduction of inspiratory stridor, although early voice alterations without recurrent nerve palsy were reported more often after LTR (34% versus 16%). All airway-related scores and quality of life measures improved significantly following both therapeutic modalities. While these results are promising, the low questionnaire response rate (63%) prompts caution.
Risk-prediction models are well-known in cardiac surgery—the EuroSCORE and STS models being some of the most recognized. They are used for risk stratification, decision-making, and benchmarking. However, development of these models can be complex and once a model is developed, it is important to validate it. This article by Grant and colleagues discusses various issues in developing and validating risk-prediction models to aid clinicians in gaining a basic understanding of the advantages and limitations of such models.