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Journal and News Scan
October 17, 2024
Submitted by: Jessica Luc
This study investigated the impact of complete revascularization (CR) versus incomplete revascularization (IR) on long-term survival in patients who underwent multivessel coronary artery bypass grafting (CABG) with either multiple arterial grafts (MAG) or a single artery with saphenous vein grafts (SAG). The analysis revealed that IR did not negatively affect long-term survival in patients who received MAG but was linked to lower survival rates in those receiving SAG. Specifically, patients with MAG IR had better long-term outcomes than those with SAG IR. Furthermore, CR combined with MAG resulted in better long-term survival compared to CR with SAG. Within the MAG cohort, no significant survival differences were observed among patients with perfect CR, imperfect CR, and IR. However, in the SAG cohort, perfect CR was associated with better survival compared to imperfect CR and IR. The study supports the advantage of MAG over SAG in terms of long-term survival, regardless of CR or IR status. The benefit of MAG may be attributed to better graft patency and reduced progression of atherosclerosis compared to SAG. The results suggest that MAG is preferable even when CR is not achievable. The limitations of this study include potential biases inherent in observational studies and a lack of functional assessment of IR.
October 17, 2024
Submitted by: Jessica Luc
The long-term benefits of total arch replacement (TAR) versus hemiarch replacement for treating aortic dissection have been debated, with most studies showing no difference in survival rates between the two methods. However, TAR may be more effective in preventing distal aortic events, particularly in patients under 70 years old. This study analyzed data to determine if age affects the benefits of TAR. The findings suggest that patients younger than 70-years-old benefit more from distal extended surgery to address primary entry tears in the descending aorta. In contrast, older patients (70 years and older) do not experience significant long-term benefits from TAR compared to hemiarch replacement. The study used a cutoff of 70 years based on receiver operating characteristic curve analysis. The German Registry for Acute Aortic Dissection Type A (GERAADA) supports these findings, noting more extensive dissection and organ malperfusion in younger patients. Although TAR with the frozen elephant trunk (FET) technique has shown promising results, especially in younger patients, the risks and benefits must be carefully weighed. The study concludes that aggressive TAR may be more beneficial for younger patients, while hemiarch replacement could suffice for older patients, even when the primary tear remains in the descending aorta.
October 17, 2024
Submitted by: Mateo Marin-Cuartas
The AVATAR Trial addressed the question of when and how to treat asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function. In the current report, the authors present the extended follow-up. The AVATAR trial randomly assigned patients with severe, asymptomatic AS (negative exercise stress testing in all patients) and LV ejection fraction greater than 50 percent to undergo either early surgical aortic valve replacement (SAVR) or conservative treatment with a watchful waiting strategy. The primary endpoint was a composite outcome of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure (HF). A total of 157 low-risk patients were randomly assigned to either the early SAVR group (n=78) or the conservative treatment group (n=79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18 out of 78 patients (23.1 percent) in the early SAVR group and 37 out of 79 patients (46.8 percent) in the conservative treatment group (hazard ratio (HR) early SAVR versus conservative treatment 0.42; 95 percent confidence interval (CI) 0.24–0.73, p=0.002). The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early SAVR group compared to the conservative group (HR 0.44; 95 percent CI 0.23–0.85, p=0.012 for all-cause death, and HR 0.21; 95 percent CI 0.06–0.73, p=0.007 for HF hospitalizations). The authors conclude that after an extended follow-up, asymptomatic patients with severe AS and normal LV ejection demonstrate better clinical outcomes with early SAVR than patients treated with conservative treatment and watchful waiting.
October 17, 2024
Submitted by: Joel Dunning
This study examined whether potassium supplementation at a lower threshold (below 3.6 mEq/L) is as effective as the standard practice (below 4.5 mEq/L) in preventing atrial fibrillation after coronary artery bypass graft (CABG) surgery. A trial involving 1,690 patients at 23 cardiac surgical centers showed no significant difference in new-onset atrial fibrillation or other clinical outcomes between the two groups. The findings suggest that the current practice of maintaining high-normal potassium levels postoperatively can be reconsidered, potentially lowering healthcare costs and minimizing unnecessary interventions.
October 10, 2024
Submitted by: Jade Qu
CT-guided transthoracic needle biopsy (TNB) has allowed for increased detection of small pulmonary nodules in lung cancer patients. However, it also poses a risk of iatrogenic damage. This single-center study aimed to investigate the risk profile of preoperative CT-guided TNB. A total of 1,077 patients with stage 1A non-small cell lung cancer (NSCLC) and no visceral pleural invasion was included; 190 of whom underwent preoperative TNB and 823 were in the non-TNB group. Postoperative CT-TNB surveillance was monitored for locoregional recurrence, and propensity score-matched cohorts were compared. The locoregional five-year recurrence-free survival (RFS) in the non-TNB cohort was 96.8 percent and 88.3 percent in the TNB cohort, with no significant difference observed. In the TNB cohort, 21.6 percent of patients experienced post-TNB pneumothorax. Based on multivariable analysis, the history of TNB was a risk factor for locoregional recurrence and a negative prognostic factor for both locoregional and overall RFS. While not conclusive, the high rate of complications associated with TNB and its effect on RFS should be considered when offering TNB preoperatively to those with early-stage lung cancer.
October 10, 2024
Submitted by: Akshay Patel
This article provides a detailed overview of using composite outcomes in clinical trials, particularly in cardiovascular and thoracic surgery. The main takeaways include the advantages of composite endpoints in increasing statistical power by combining multiple relevant outcomes, which can reduce sample size and improve trial feasibility. However, the authors also highlight key issues such as the potential for bias, the halo effect, and the importance of carefully selecting and interpreting composite outcomes. They emphasize the necessity of analyzing individual components within a composite to avoid misleading conclusions about treatment efficacy. The article also discusses the win ratio approach, a method that prioritizes clinically important outcomes when evaluating composite endpoints. Understanding the nuances of this statistical method is crucial for interpreting trial results and optimizing patient care.
October 10, 2024
Submitted by: Francesco Pollari
The aim of this study was to compare the clinical outcomes between surgical cut-down (SC) and the percutaneous (PC) approach. In the matched population, 15 out of 323 patients (4.6 percent) in the SC group versus 34 out of 323 patients in the PC group (11 percent) experienced minor vascular complications (p = 0.02). There was no significant difference for major vascular complications, with rates of 1.5 percent and 1.9 percent. The rate of minor bleeding events was higher in the percutaneous group (11 percent versus 3.1 percent, p <.001). The SC group also experienced a higher rate of non-vascular-related access complications, with minor complications at 8 percent versus 1.2 percent and major complications at 2.2 percent versus 1.2 percent (p < 0.001). Surgical cut-down for TF-TAVI did not alter the 30-day mortality rate and was associated with reduced minor vascular complications and bleeding. The PC approach showed a lower rate of non-vascular-related access complications and a shorter length of stay. The choice of approach should be tailored to the patient's clinical characteristics.
October 10, 2024
Submitted by: Jessica Bogensberger
Myocardial infarction due to coronary artery disease (CAD) is the leading cause of death worldwide. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are the primary treatment modalities of choice for patients with CAD. Surgical myocardial revascularization remains the gold standard for patients with more complex CAD. For decades, surgical myocardial revascularization, using the in situ left internal mammary artery (LIMA) bypass for the anterior wall of the heart and single aortocoronary venous bypasses for the lateral and posterior areas of the heart, have been the standard cardiac surgical procedure. The dynamics of increasingly older and sicker patients, along with the efforts of cardiac surgeons to perfect the surgical treatment of CAD, have led to a variety of different surgical revascularization concepts. The primary goal is to complete revascularization of all coronary arteries compromised by significant stenoses. In many cardiac surgery centers, there is a trend toward extended arterial revascularization, especially in younger patients, because arterial coronary bypasses are considered to have better long-term openness rates than venous bypasses. In situ bypass with the LIMA to the left anterior descending (LAD) artery, combined with an additional arterial bypass with proximal anastomosis to the LIMA to the affected branches of the circumflex system and the right coronary artery, have been established by many surgeons.
The proximal anastomosis of the right internal mammary artery (RIMA) as a free graft of the radial artery (RA) with the LIMA is performed in a T- or Y-shape (fig. 1), respectively, to be able to supply all cardiac regions with the limited available arterial graft material in terms of length. However, complete arterial revascularization cannot be achieved in every patient and should not be forced under any circumstances.
October 3, 2024
Submitted by: Jessica Luc
Mitral annular calcification (MAC) complicates mitral valve surgery and often necessitates mitral valve replacement (MVR) due to challenges in valvular repair. Traditional methods for addressing MAC involve extensive debridement, which can increase perioperative risks. This report explores an innovative technique using ultrasonic emulsification with the Sonopet Qi device to decalcify the mitral annulus allowing successful mitral valve repair in a patient with severe MAC. The case involves a 53-year-old woman with significant mitral regurgitation and severe MAC, who was initially planned for traditional posterior bar decalcification. However, ultrasonic emulsification was chosen to minimize risks associated with traditional debridement methods. This technique uses ultrasonic waves to fragment and aspirate calcium while preserving surrounding tissues and reducing embolic risks. Compared to conventional methods, ultrasonic emulsification offers precise debridement with potentially fewer complications. This case demonstrates that ultrasonic emulsification can be a valuable addition to surgical strategies for MAC, potentially reducing perioperative risks and enabling complex mitral valve repair.
October 3, 2024
Submitted by: Jessica Luc
Aortic stenosis affects more than 9 million people worldwide and is commonly treated with surgical aortic valve replacement (SAVR), which is known for producing excellent long-term outcomes. Recent advancements in transcatheter aortic valve replacement (TAVR) have shown noninferior or improved outcomes compared to SAVR across various risk levels. Despite TAVR's growth, innovations in surgical valves, such as sutureless aortic valves (SURD), are maintaining SAVR's relevance. The Perceval S valve, a sutureless option, has shown promising early and midterm results. It reduces cardiopulmonary bypass and aortic cross-clamp times, which are linked to lower morbidity and mortality. This review highlights the design, deployment, and clinical outcomes of the Perceval S valve. While it offers benefits similar to TAVR, it presents unique advantages for certain patients, including those requiring minimally invasive SAVR (such as robotic, mini thoracotomy, or mini sternotomy approach), those with small aortic annuli, patients undergoing concomitant procedures aimed at shortening cardiopulmonary bypass times, and redo scenarios. However, it presents unique risks as well, including an increased risk of postoperative need for permanent pacemaker implantation. Future research is needed to refine techniques and further evaluate long-term outcomes.