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Journal and News Scan
January 31, 2017
Submitted by: Rakesh Arora
In this is review article the authors have proposed a "3-strike" model of risk that increases the likelihood of experiencing postoperative delirium in older adults undergoing cardiac surgery. The 3 strikes consists of a baseline vulnerability (such as frailty), the intraoperative surgical stressor and the postoperative hemodynamic perturbations (and other process of care factors) that can contribute to the occurance of postoperative delirium. Pratical tips on how cardiac team can begin to address this important issue are provided in this review.
The authors assessed the influence of patch material type on the incidence of recoarctation in infants undergoing Norwood I repair for hypoplastic left heart syndrome. Among 145 patients, recoarctation developed in 18% at a median of 4.3 months. At 2 years, freedom from recoarctation was about 85% for homograft and autologous pericardium, whereas it was 30% for equine pericardium; use of the latter was the only risk factor for recoarctation in multivariable analysis.
The authors investigated the efficacy of vancomycin paste applied to the sternal edges during cardiac surgery in reducing the risk of deep sternal wound infection among nearly 14,500 cardiac surgical patients. The incidence of such infections was 09.%. In a multivariable analysis, BMI, NYHA class, and the STS DSWI risk index were significantly associated with deep sternal wound infection. Vancomycin paste did not reduce the incidence of infection.
Mitral valve surgery complicated by atrioventricular groove disruption has a high mortality rate. The authors describe results of an external repair for this injury, directly suturing the atrioventricular groove. In a 20-year experience involving over 3,000 mitral valve operations, 13 such injuries occurred. 30-day and hospital mortality were 15% and 23%. 1-year survival was 73%. The external repair approach appears to offer favorable results after this devastating complication.
Using pigs as an experimental model, the authors demonstrated incorporation of bioengineered tracheal grafts in large tracheal defects. The grafts were constructed of acellular bovine dermis extracellular matrix and human mesenchymal stem cells incubated with chondogenic factors. The authors demonstrated that the use of stem cells resulted in chondrogenesis, and that the grafts developed neovascularization and epithelialization, all of which are important in supporting tracheal healing and growth.
January 27, 2017
Submitted by: J. Rafael Sadaba
Results are reported of a global feasibility study in which 30 patients at high risk for mitral valve surgery were enrolled at 8 study sites. Patients underwent transapical mitral valve replacement with a Tendyne transcatheter mitral valve. A mitral prosthesis was successfully implanted in 93%. In these 28 patients, the residual MR (valvular or paravalvular) was grade 0 in all but 1 patient and there was no LVOT obstruction. There was no device embolization or cardiac perforation. At 30 days, there was only one death (3.3%). Repeat echocardiography showed no evidence of prosthesis dysfunction. There were no strokes, no myocardial infarctions, and no additional device-related complications during hospitalization. The authors conclude that transcatheter mitral valve replacement using a prosthesis specifically designed for the mitral valve is feasible and can be performed safely.
January 26, 2017
Submitted by: Joel Dunning
This New STS Expert Consensus Statement is now available to download. For the first time this protocol gives units who look after patients after cardiac surgery a complete guide for the management for patients who arrest. Most notably there is a recommendation that patients should undergo an emergency resternotomy within 5 minutes if quickly reversible factors are not found, in order to save those patients who have arrested due to tamponade, for whom external CPR is ineffective. There are recommendations for the organisation of the team, recommendations against the use of epinephrine, recommendations on how to identify rapidly reversible causes for the arrest and importantly there is advice as to how to implement this guidance into your unit and how to get trained. The APACVS have also set up a training arm to help with the implementation of the protocol that can be found at www.csu-als.com
January 25, 2017
Submitted by: Joel Dunning
In a bold and very challenging move, thoracic surgeons at Toronto General Hospital (TGH) removed severely infected lungs from a dying mom, keeping her alive without them for six days, so that she could recover enough to receive a life-saving lung transplant.
January 13, 2017
Submitted by: Aamir Shah
This article is a propensity matched analysis comparing patients undergoing hybrid coronary revascularization (HCR) with minimally invasive left internal mammary artery to left anterior descending artery (LAD) bypass and percutaneous coronary intervention (PCI) to non-LAD arteries to patients undergoing conventional coronary artery bypass grafting (CABG) with either single (SIMA) or bilateral internal mammary arteries (BIMA). A total of 306 patients underwent HCR from 2003 to 2013 compared with 8254 patients undergoing CABG. In the HCR group LIMA harvest was performed endoscopically before 2009 and with robotic assistance thereafter. In the matched study populations, cardiopulmonbary bypass was used in 0% of patients in HCR group, 21% in SIMA group and 7% in BIMA group. Patient factors that were associated with HCR use were older age, lower body mass index, history of PCI, and 2-vessel coronary disease. In the HCR group, 84% of non-LAD lesions were treated with drug eluting stents. At 30 days, there was no significant difference in major cerebrovascular and cardiac events between groups. In hospital complications, the need for blood transfusions, and hospital stay duration were lower for the HCR group. There was no difference in survival between the matched groups at midterm followup (median follow-up 2.8 years). The authors conclude that HCR in selected patients may be a safe and less invasive alternative to conventional CABG with similar short and midterm outcomes.
January 13, 2017
Submitted by: Arie Blitz
With the everpresent question of potentially extending LVAD therapy to ambulatory patients with advanced heart failure, the authors--using a Markov model--projected the incremental cost-efffectiveness ratio (ICER) of DT LVADs in this population as compared to conventional medical therapy. The authors find that, although LVADs clearly extend quality-adjusted life-years (QALYs), the ICER is >$200K per QALY. (Conventional cut-offs for ICER acceptability range from <$50K to <$100K.) This ICER is thus cost-ineffective at present. The study finds that this excessive cost is driven predominantly by follow-up care and readmissions, which suggests a potential target for improving ICER in the future.