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Journal and News Scan
Flynn and colleagues evaluated their center’s implementation of a protocol for extubation within six hours after cardiac surgery, focusing on the rate of adverse events before and after protocol implementation particularly for those patients at highest surgical risk. The authors analyzed prospectively-collected data for patients undergoing cardiac operations within six months of the initiation of the early extubation protocol, 181 patients before and 152 after. They found no differences in the total number of adverse events (renal failure, reintubation, 30-day mortality, or postoperative stroke) before and after the protocol was initiated (16% versus 19%, p = 0.557). In a subset analysis focusing specifically on patients with STS predicted morbidity or mortality score over 40% (8 patients before, 6 patients after the protocol began), the number of adverse events were not different and the median ventilation time was reduced to less than six hours.
The authors conclude that these results are encouraging but merit further investigation, considering the small sample size.
Ishii and colleagues present a narrated video on robotic mitral valve repairs. The lecture includes a detailed description on how to perform safe, reliable, and durable repairs for a range of mitral valve pathologies. The authors discuss an illustrative procedure, performed for a 63-year-old man with severe mitral regurgitation secondary to previous medically-managed infective endocarditis.
This review summarizes the current understanding of the inherited basis for aortic aneurysmal disease and clearly highlights the need to differentiate between thoracic and abdominal aortic manifestations. Approximately 20% of thoracic aortic aneurysms are associated with an autosomal pattern of inheritance from a mutation in a single gene, whereas abdominal aortic aneurysms (AAAs) do not typically demonstrate such inheritance but rather seem to present as a polygenic disorder involving variants of weaker effect. This notwithstanding, there are some distinct biological pathway similarities between thoracic aortic disease (TAD) and AAA; these include the TGF-β and low-density lipoprotein receptor-related protein (LRP1) pathways, as well as other aspects of vascular smooth muscle cell function.
Currently, over a dozen causative genes have been validated for heritable TAD. Each confers a high risk for disease, and genetic testing for these genes is now offered clinically. The situation is far less advanced for AAA, and although polygenic AAA risk scores are being developed, using genetic variants to predict AAAs has not progressed to the extent that it can be used to identify at-risk individuals.
The American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), The Society of Thoracic Surgeons (STS), and the American Association for Thoracic Surgery (AATS), along with key specialty and subspecialty societies, have published a revision of the appropriate use criteria (AUC) for coronary revascularization in patients with stable ischemic heart disease (SIHD). The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.
Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status, risk level as assessed by noninvasive testing, coronary disease burden, and in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria.
A separate independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the middle range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated.
Patient Care and General Interest
The Donor Alliance observes National Donor Day on February 14th in the US, encouraging people to #StartTheConversation about being an organ donor with their families.
A patient who received a heart-lung transplant shares images of artwork that commemorates both her original and her transplanted organs.
Building on the popularity of the #10YearChallenge, these pictures on the Today Show website highlight successes for patients with congenital heart defects at Children’s Healthcare of Atlanta in Georgia, USA.
Drugs and Devices
Foldax, Inc, was granted investigational device exemption approval from the US Food and Drug Administration for an early feasibility study of their Tria heart valve, which is made from a material the company hopes will provide greater durability.
Research, Trials, and Funding
Researchers from West Virginia Heart and Vascular Institute in the USA find that the rate of emergent percutaneous coronary intervention after coronary artery bypass grafting is 2.6%, higher than was expected.
A new series from the British Medical Journal, NIHR Signals, aims to provide regular summaries of studies with particular relevance to clinical practice. Screening for atrial fibrillation is covered in this week’s summary.
Saran and colleagues sought to evaluate the prevalence of mitral annual calcification (MAC) in patients undergoing valve replacement and to characterize the effect of MAC on postsurgical outcomes. They also discuss their conservative operative approach.
The authors retrospectively analyzed medical records for 496 patients who underwent isolated primary mitral valve replacement at their institution between 2000 and 2015. MAC was present in 115 patients (23%). Although patients with MAC had worse survival than patients without (unadjusted hazard ratio, 1.62; 95% confidence interval 1.20 to 2.18; p = 0.002), the authors conclude that this was due to the prevalence of comorbidities in this group. Multivariable analysis identified risk factors for mortality that included older age, diabetes, dialysis, previous aortic valve surgery, and bioprosthetic valve placement, but not MAC. The incidence of stroke was higher in patients with any mitral calcification, underscoring the importance of thoroughly clearing calcium debris from the surgical field.
Yang and colleagues investigated the use of intestinal flaps for the reconstruction of the cervical esophagus. They reviewed 22 patients with intestinal segments used to salvage failed primary esophagus reconstruction. There was one case of flap failure. The majority of patients did not have any major postoperative complications, and in 21 patients the esophageal continuity and oral intake was successfully restored.
In the latest issue of JACC, the Stanford group led by Dr. Dake published a retrospective study to evaluate the effectiveness of thoracic endovascular aortic repair (TEVAR) compared to open surgical repair for descending aortic aneurysms.
Among 4580 patients treated between 1999 and 2010, 1,235 patients with open surgical repair patients were matched to 2,470 undergoing TEVAR with follow-up through 2014. The primary endpoint was all-cause mortality, and the secondary endpoint was open or endovascular re-intervention on the descending thoracic aorta. At 180 days, mortality was higher in the surgical repair group (23.8% vs TEVAR 10.2%). Despite a reduced risk for late death (hazard ratio, 0.86, P = 0.004) and reintervention (hazard ratio: 0.40, P < .001) in patients undergoing open surgical repair, the restricted mean survival time difference favored TEVAR, with a difference of -209.2 days (95% CI, -298.7 to -119.7 days; P < .001), revealing a substantial survival advantage with TEVAR at 9 years.
The study concluded that open surgical repair was associated with increased risk of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.
In this paper, Dr Coselli and colleagues analyzed their experience with spinal cord deficit (SCD) after 1114 extent II open thoracoabdominal aortic aneurysm repairs performed from 1991-2017.
The incidence of SCD was 13.6% (151 of 1114), 86 (7.7%) with persistent paraplegia or paraparesis (PPP) (51 paraplegia, 35 paraparesis) and 65 (6.1%) with transient paraplegia or paraparesis. Patients with SCD were older (median 68 versus 65 years old, P<0.001), and they had more rupture (6.6% versus 2.2%, P=0.002) and urgent/emergent repair (25.2% versus 16.8%, P=0.01) than those without. PPP developed immediately in 47 patients (4.2%) and was delayed in 39 (3.5%). Urgent/emergent repair (relative risk ratio [RRR]=2.31, P=0.002), coronary artery disease (RRR=1.80, P=0.01), and chronic symptoms (RRR=1.76, P=0.02) independently predicted PPP. Reattaching intercostal/lumbar arteries (RRR=0.38, P<0.001) and heritable disease (RRR=0.36, P=0.01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without.
This report adds important data to our knowledge of spinal cord deficit after extent II open TAAA repair, which warrants further studies.
This article concludes that five-year survival and morbidity rates in patients over 75 years of age did not differ between off-pump and on-pump groups. The main determinant of poorer long term outcome was incomplete revascularization.