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Journal and News Scan
In the February issue of The Annals, The Society of Thoracic Surgeons published the first annual report after the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) joined the STS National Database in January 2018. This report summarizes the outcomes in patients (≥19 years of age) undergoing durable MCS implant between June 23, 2006, and December 31, 2017.
Among 25,145 patients, 18,539 (74%) received continuous flow left ventricular assist devices (CF LVADs), 667 (2.6%) had a right ventricular assist device (RVAD) with CF LVAD, 339 (1.3%) received a total artificial heart, and 20 (0.07%) received an isolated RVAD. Of the CF LVADs, mean age was 57 ± 1 years, 26% were listed for transplantation, and 51% were in cardiogenic shock (profile 1 to 2) preoperatively. CF LVADs included 14,527 axial flow (78%) and 4,012 centrifugal flow (22%) devices. Recently (2012-2016), more patients are in Intermacs profile 3, with better renal and hepatic function, and received implants for destination therapy (48%), with a centrifugal flow device (51%).
Mean CF LVAD support duration was 20 months. Survival for isolated CF LVADs was 83% at 1 year and 46% at 5 years. One-year survivals for centrifugal versus axial flow devices were 85% and 84%, respectively. Patients with concomitant RVAD support had 1-year and 5-year survivals of 58% and 28%, respectively. Freedom from all-cause readmission was 70% at 1 month and 20% at 1 year. At 1 year, stroke occurred in 20% with centrifugal flow and 13% with axial flow support (p < 0.001), gastrointestinal bleeding affected 20% with centrifugal flow devices and 25% with axial flow devices (p < 0.001), and pump-related infection occurred in 28% of patients with centrifugal flow devices versus 25% with axial flow devices (p = 0.01). Neurologic dysfunction (19% of deaths) and multisystem organ dysfunction (15%) were the most common causes of death.
Park and colleagues evaluated the effect of neoadjuvant chemotherapy for thymic cancers, comparing postoperative outcomes and long-term survival between 102 matched pairs of patients who underwent either upfront resection or resection after neoadjuvant chemotherapy. Postoperative complications and hospital length of stay were similar between the groups, as were three-year recurrence-free survival and five-year overall survival.
On February 4, 2019, Cook Medical announced recent approval from the US Food and Drug Administration for its Zenith Dissection Endovascular System. The system consists of a proximal stent-graft component and a distal bare stent component. It provides a less invasive alternative to open surgery for repair of type B dissections. The device will be available for sale in the United States in the coming months.
In this prospective single-institution study, functional status trajectory one year after intervention was compared for transcatheter (TAVR) versus surgical aortic valve replacement (SAVR). A moderate/large decline compared to preintervention status occurred in 23% of TAVR patients and 4% of SAVR patients. A frailty index, postoperative delirium, and procedure-related complications were associated with postintervention decline.
In this systemic review and meta-analysis, the authors compared outcomes for patients undergoing aortic root replacement to those undergoing a David operation. Mosbahi and colleagues analyzed 27 studies that included a total of 3058 patients with acute type A aortic dissections. In-hospital mortality and midterm survival both favored aortic valve reimplantation. Freedom from valve-related reintervention was 100% (confidence interval (CI) 93.7 - 100%) in patients who underwent reimplantation compared to 94.6% (CI 86.7 - 99.1%) for a composite valve graft intervention. The authors conclude that in type A dissection the reimplantation procedure (David operation) provided a superior outcome.
The Arterial Revascularization Trial Investigators recently published the outcomes of coronary artery bypass grafting (CABG) using bliateral versus single internal thoracic artery (ITA) after 10 years. Patients were randomly assigned to CABG using the bliateral or single ITA. The primary outcome was death from any cause at 10-year follow-up. Secondary outcomes were the composite of death from any cause, myocardial infarction, or stroke, rate of repeat revascularization, and safety outcomes. At 10 years, death occurred in 644 patients (20.8%), with 315 deaths (20.3%) occurring in the bilateral ITA group versus 329 (21.2%) in the single-graft group (P=0.62). The number of secondary events was 385 (24.9%) in the bilateral ITA versus 425 (27.3%) in the single ITA group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). No significant differences were found between the two groups in the rate of death from any cause or the rate of the composite outcome of death, myocardial infarction, or stroke. Further studies are needed to determine whether multiple arterial grafts can provide better outcomes than a single ITA graft.
In a letter to healthcare providers, the US FDA summarized a recent evaluation of a postapproval study of the Abiomed Impella RP system. In clinical trials, 73% of patients survived 30 days after device explant, hospital discharge, or to definitive intervention. In the postapproval study, just over 17% of patients met this goal. There is some evidence to suggest that patients in the postapproval study were suboptimal candidates for the system.
In this retrospective cohort study, Dr Ehrlich and his colleagues reported excellent early and long-term results of thoracic endovascular aortic repair (TEVAR) for 55 high-risk patients with life-threatening acute complicated type B aortic dissection. The mean age of patients was 52 ± 13 years. The indications for TEVAR included malperfusion (58%), aortic rupture (18%), or persistent untreatable pain with true lumen reduction or rapid aortic diameter enlargement (24%). The technical success was 91% and overall in-hospital mortality rate was 9%. At 5 years, survival was 75%, with 77% freedom from aorta-related death and 63% freedom from reintervention.
Patient Care and General Interest
Former Indian Prime Minister Manmohan Singh chimes in to the #10YearChallenge with a focus on his heart surgery.
A New England Journal of Medicine case report on trachealization of the esophagus made headlines, describing a patient who had sought care after getting a pizza roll stuck in his throat.
An update to the 2014 US guidelines on managing patients with atrial fibrillation was issued by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society.
Research, Trials, and Funding
Cell-free DNA might be useful to monitor patients with transplanted lungs for transplant rejection, say researchers from the US National Heart, Lung, and Blood Institute.
A partnership between space technology company Techshot and NASA aims to study cardiac tissue growth in zero gravity.
Research presented at the recent Society of Thoracic Surgeons’ Annual Meeting in San Diego, California, suggests that cardiac surgery outcomes in the US are similar at the beginning and the end of the academic training year.
Martin and colleagues describe two efforts to improve outcomes within the congenital heart disease field: the Improving Pediatric and Adult Congenital Treatments (IMPACT) Registry and the National Pediatric Cardiology-Quality Improvement Collaborative (NPC-QIC). The authors discuss some of the insights that have been gained using data from the IMPACT Registry and outcome improvements that have resulted from the collaborative structure of the NPC-QIC. They emphasize the importance of both registries and learning collaboratives to ensure that best practices are both identified and implemented.