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Journal and News Scan

Source: JACC: Heart Failure
Author(s): Khadijah Breathett, Wenhui G. Liu, Larry A. Allen, Stacie L. Daugherty, Irene V. Blair, Jacqueline Jones, Gary K. Grunwald, Marc Moss, Tyree H. Kiser, Ellen Burnham, R. William Vandivier, Brendan J. Clark, Eldrin F. Lewis, Sula Mazimba, Catherine Battaglia, P. Michael Ho, Pamela N. Peterson

Using the Premier healthcare database, the authors analyzed the data of over 100,000 adult patients admitted to an ICU in the U.S. with a primary diagnosis of heart failure from 2010-2014.  Hierarchical logistic regression models revealed that the likelihood of care by a cardiologist was 42% higher for white as opposed to black patients with heart failure.  Cox regression showed that care by a cardiologist was associated with a 20% higher likelihood of survival.

Question:  Is this healthcare disparity a true disparity based on race, or are other confounding and unaccounted for variables responsible?

Source: New England Journal of Medicine
Author(s): Mario Gaudino, Umberto Benedetto,Stephen Fremes, Giuseppe Biondi-Zoccai, Art Sedrakyan, John D. Puskas, Gianni D. Angelini, Brian Buxton, Giacomo Frati, David L. Hare, Philip Hayward, Giuseppe Nasso, Neil Moat, Miodrag Peric, Kyung J. Yoo, Giuseppe Speziale, Leonard N. Girardi, David P. Taggart, for the RADIAL Investigators

The authors performed a patient-level meta-analysis of six randomized trials comparing left internal mammary artery (LIMA) + saphenous vein graft (SVG) versus LIMA + radial artery graft. In a total of more than 1000 patients and at a follow-up of 60 months, the incidence of adverse cardiac events (death, myocardial infarction, or repeat revascularization) was significantly lower in patients with a radial artery graft as compared with those in the SVG group (hazard ratio, 0.67; 95% confidence interval, 0.49 - 0.90; p = 0.01). Moreover, the patency rate at 50 months of angiographic follow-up was higher in the LIMA + radial artery group. These results emphasize the importance of using more arterial grafts.

Source: News from around the web.
Author(s): Claire Vernon

Patient Care

The Jos University Teaching Hospital in Nigeria has received a donation of surgical equipment for cardiothoracic surgery from Project CURE, which will allow the hospital to offer more surgical services to patients.

Italy’s former president, Giorgio Napolitano, underwent emergency surgery for a ruptured aorta.

A former goalkeeper for the national Pakistani field hockey team is in need of a heart transplant and has appealed to the Indian government for a medical visa.

 

Drugs and Devices

The CoAp Pro device from HeartStitch, designed to provide a percutaneous suture-based approach for mitral valve remodeling and repair, has received CE Mark approval in the European Union.

The US Food and Drug Administration has expanded approved use of osimertinib from AstraZeneca to include first-line treatment for metastatic non-small cell lung cancer with epidermal growth factor receptor mutations.

A planned firmware upgrade for certain implantable cardiac devices from Abbott includes a cybersecurity update.

 

Research, Trials, and Funding

The VEST US trial has enrolled the first 20 patients. The trial will evaluate the safety and effectiveness of a device for treating saphenous vein graft disease after coronary artery bypass grafting.

Source: The Annals of Thoracic Surgery
Author(s): Rajdeep Bilkhu, Pouya Youssefi, Gopal Soppa, Panagiotis Theodoropoulos, Simon Phillips, Bernard Liban, Anne Child, Maite Tome, Justin Nowell, Rajan Sharma, Mark Edsell, Marjan Jahangiri

The authors retrospectively evaluated the long-term fate of the aortic arch in 168 patients with bicuspid aortic valves who had undergone either ascending aortic (24%) or aortic root (76%) replacement.  At a median follow-up of 5.9 years, the mean aortic arch diameter went from 2.9 cm preoperatively to 3.0 cm at follow-up (p=ns).  The authors conclude that prophylactic arch replacement in this population is not indicated, and perhaps neither is long-term aortic surveillance.

Source: The Annals of Thoracic Surgery
Author(s): Raheel Rizwan, Farhan Zafar, Roosevelt Bryant III, James S. Tweddell, Angela Lorts, Clifford Chin, David L. Morales

Rizwan and colleagues retrospectively reviewed data from the United Network for Organ Sharing database for pediatric donor hearts and transplants from 2000 to 2015. The authors focused on two cohorts: recipients who accepted a heart with three or fewer prior refusals due to donor quality (RDQ), and recipient accepting hearts with more than three RDQs. Recipients who were adolescents, on extracorporeal support, or in need of a retransplant were more likely to accept a donor heart with a high number of RDQs. Despite this, the rates of posttransplant stroke, dialysis, acute rejection, and rejection within one year were not different between the two groups. Additionally, accepting a heart with more than three prior RDQs did not predict one-year or overall mortality (p = 0.427 and p = 0.626, respectively).

Source: JAMA
Author(s): Qiang Zhao, Yunpeng Zhu, Zhiyun Xu, Zhaoyun Cheng, Ju Mei, Xin Chen, Xiaowei Wang

The authors report on a randomized, multicenter, open-label, clinical trial involving 500 patients with 1460 saphenous vein grafts (SVG) who were assigned to three groups: (1) ticagrelor + asprin (ASA), (2) ticagrelor alone, or (3) ASA alone.  Neither patients nor physicians were blinded to the allocation.  The primary outcome was SVG patency at one year, assessed by either coronary angiography or CT angiography.

Results: The SVG patency rates for groups 1,2, and 3 were 88.7%, 82.8%, and 76.5%.  The differences between group 1 and group 3 were significant at p<0.001.  The differences between the remaining groups were not significant.

Conclusion: Among patients undergoing elective coronary artery bypass grafting, the combination of ASA and ticagrelor resulted in higher SVG patency at one year over ASA alone.  Five major bleeding episdoes occurred during one year of follow-up, all in either group 1 or 2.

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Brendon M. Stiles, Mohamed Rahouma, Mohamed Kamel, Hussein Abu Nasar, Andrew B. Nguyen, Sebron Harrison, Benjamin Lee, Jeffrey L. Port, Nasser K. Altorki

Stiles and colleagues retrospectively analyzed prospectively-collected data on approximately 3,200 surgical lung cancer patients, finding that more than one fifth of these patients are never-smokers. Compared to patients with a history of smoking, never-smokers were more likely to be younger, female, and to suffer from adenocarcinoma. Despite these demographic and disease differences, these patients had similar survival and risk for recurrence as smokers.

Source: News from around the web.
Author(s): Claire Vernon

Patient Care

The Chinese Red Cross has announced that 25 Afghan children with congenital heart disease will receive free medical treatment in China.

The National Health System England has chosen HeartFlow™ FFRct Analysis to be funded through the Innovation and Technology Payment program, which may allow more patients with coronary artery disease to avoid angioplasty.

The Children’s Heart Foundation and the Adult Congenital Heart Association will host a number of Congenital Heart Walks around the US in 2018 to promote disease awareness and to raise funding for research and educational programs.

 

Drugs and Devices

In the latest development in a patent spat over transcatheter heart valve technologies, the European Patent Office has revoked a patent owned by Edwards Lifesciences in favor of Boston Scientific. In March, however, the US Patent and Trademark Office ruled in favor of Edwards Lifesciences that claims made by Boston Scientific were invalid.

 

Research, Trials, and Funding

Researchers report that 45% of patients with non-small cell lung cancer who received nivolumab prior to surgery showed a major pathologic response in the resected tumor, presenting their findings at the recent annual meeting of the American Association for Cancer Research.

Cardiome Pharma has completed enrollment for the Phase 4 SPECTRUM study in the EU evaluating vernakalant hydrochloride for recent onset atrial fibrillation.

A recent study of Swedish adults found that nut consumption was inversely associated with one’s risk for atrial fibrillation and for heart failure.

Source: JACC: Cardiovascular Interventions
Author(s): Mateusz Tajstra, Tomasz Hrapkowicz, Michał Hawranek, Krzysztof Filipiak, Marek Gierlotka, Marian Zembala, Mariusz Gąsior, Michael Oscar Zembala, and POLMIDES Study Investigators

The authors present the 5-year follow-up results of the HYBRID trial, wherein 200 patients with multivessel disease requiring revascularization were randomized to either conventional coronary artery bypass grafting (CABG) or hybrid coronary revascularization (HCR).  Notably, the patients undergoing HCR  had a LIMA to LAD via a minimally invasive approach combined with percutaneous coronary intervention (PCI) of the remaining vessels.

The following table summarizes the results from this trial:

Outcome                                               CABG                    HCR                p-value

All-cause mortality                          9.2%                    6.4%                   0.69

Myocardial infarction                       7.2%                   3.4%                   0.30

Repeat revascularization             45.4%                 37.2%                0.38

Stroke                                                     4.1%                   2.1%                   0.35

MACCE                                                   53.4%                 45.2%                0.39

The authors conclude that there were no differences in outcomes between the two types of revascularization.


Comment:  Although none of the differences achieved statistical significance, there does appear to be a trend for better outcomes with HCR.  The lack of significance may be related to inadequate power of the study to detect a difference.

Question:  Is it not time to rethink our approach to HCR?  Most centers are approaching the procedure with a minimally invasive approach using a single mammary artery.  If our main concern is outcomesas it should beis it not time to reassess HCR as a conventional or minimally invasive procedure utilizing both LIMA and RIMA for appropriate targets, and PCI for the rest?  This would seem to be the optimal approach, so that the patient gets the true benefit of both worlds: the superiority of bilateral mammary revascularization over any alternative conduits, and the superiority of PCI over SVG.  What do you think?

Source: The Annals of Thoracic Surgery
Author(s): Aleksander Zywot, Christine S.M. Lau, Nina Glass, Stephanie Bonne, Franchesca Hwang, Koren Goodman, Anne Mosenthal, Subroto Paul

Coronary artery bypass grafting (CABG), the second most common cardiac procedure in the US, was added to the US Hospital Readmissions Reduction Program in 2015. Given the relatively high rate of readmission after CABG, Zywot and colleagues sought to develop a scale for predicting readmission risk. Using the State Inpatient Database discharge records of 126,519 patients from New York and California, the authors found that comorbidities such as renal failure (OR, 1.56) and congestive heart failure (OR, 2.82) were strongly predictive of readmission. Older age, female gender, African American ethnicity, and not having private insurance also predicted a higher readmission rate. Factors that were predictive of and associated with readmission were used to develop a scale of readmission risk, which was shown to be a good predictor of readmission in a validation cohort.

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