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Journal and News Scan

Source: European Journal of Cardiothoracic Surgery
Author(s): Doose C, Kütting M, Egron S, Farhadi Ghalati P, Schmitz C, Utzenrath M, Sedaghat A, Fujita B, Schmitz-Rode T, Ensminger S, Steinseifer U.

Valve in valve transcatheter aortic valve implantation (ViV-TAVI) is an alternative to redo surgical aortic valve replacement (SAVR) in inoperable patients and inpatients at high operative risk. This has become even more important now that approximately 80% of all SAVR are bioprostheses and bioprostheses are implanted at younger age. Several TAVI valves have received CE mark and premarket approval for use in degenerated bioprosthesis. This study analysed the effects of design of four different surgical bioprostheses on the hydrodynamic function of an Edwards Sapien XT valve implanted as a ViV-TAVI.

 

Main findings of this study were:

  • Although there was complete coaptation of the leaflets in all 23-mm label-size ViV combinations, there were considerable differences in regurgitation measurements. This means the differences are attributable to paravalvular leakage. The Sapien XT in the Trifecta and the Perimount had the largest paravalvular leakage compared to the Aspire and Mosaic valves.
  • The paravalvular leakages are most likely the result of different valve material as the porcine leaflets of the Aspire and the Mosaic are less stiff and provide better seal.
  • Surgical valves with externally mounted leaflets (Trifecta) have an increased risk of paravalvular leakage in the ViV combination.
  • On the other hand, mean pressure gradient (MPG) was lower in valves with a higher surgical inner diameter (the Perimount and Trifecta valves).
  • Higher MPG was the result of underexpansion of the Sapien XT in the Trifecta and Mosaic valves, leading to axial overlap of the leaflets.

In conclusion:

This study showed that surgical valves with a large valve area improved hemodynamics for future ViV-TAVI combinations. Moreover, internally mounted leaflets seem to decrease the risk of paravalvular leakage. 

Although this is an interesting study, this bench test study was limited to 23mm surgical valves and no calcifications or pannus of the surgical valves were simulated. Use of the valve-in-valve app developed by Dr. Bapat, remains helpful for clinicians making decisions on which TAVI valve is recommended in a specific surgical valve (https://itunes.apple.com/nl/app/valve-in-valve/id655683780?mt=8

 

Source: Annals of Thoracic Surgery
Author(s): Emanuela Taioli, Philip Kent Paschal, Bian Liu, Andrew J Kaufman, Raja M. Flores

This systematic review of the literature evaluated reported outcomes of myasthenia gravis in patients with and without thymectomy.  Among over 10,000 patients evenly divided between thymectomy and medication alone, the likelihood of remission was 31% vs 15%, OR 2.44. 

Source: Annals of Thoracic Surgery
Author(s): Vladimiro L. Vida, Chiara Tessari, Biagio Castaldi, Massimo A. Padalino, Ornella Milanesi, Dario Gregori, Giovanni Stellin

A single institution experience during 22 years for early repair of complete AV canal defects (CAVCD) is reported.  Repair was performed in 159 pts between 8 and 12 weeks of age.   Operative mortality was 1.9% and later mortality was 7.7%.  13% required reoperation during long-term follow-up, primarily for left AV valve regurgitation.  Left AV valve performance at last follow-up was significantly worse in pts older than 3 mons when repaired.

Source: Annals of Thoracic Surgery
Author(s): Lucas Goense, Peter S.N. van Rossum, Jelle P. Ruurda, Marco van Vulpen, Stella Mook, Gert J. Meijer, Richard van Hillegersberg

This retrospective single institution study evaluated the relationship between radiation dose to the gastric fundus and the incidence of esophageal anastomotic leak after esophagectomy for cancer.  The leak rate was 26%.  Pts with a leak had a significantly higher RT dose to the gastric fundus.  Using a cut point of 31.4 Gy, leak rates were 43% vs 15% for the high and low dose radiation exposure.  Radiation dose was an independent predictor of anastomotic leak in multivariable analysis.

Source: Annals of Thoracic Surgery
Author(s): Suvitesh Luthra, Miguel M. Leiva Juárez, Eshan Senanayake, Heyman Luckraz, John S. Billing, James Cotton, Michael S. Norell

In this  retrospective study of propensity-matched patients undergoing CABG, the authors queried whether prior PCI adversely affected outcomes.  9% of over 4500 pts undergoing first time CABG had prior PCI.  There was no difference between the groups with regard to hospital mortality or 10-year survival. 

Source: Journal of Thoracic Oncology
Author(s): Pamela Samson, Clifford Robinson, Jeffrey Bradley, A. Craig Lockhart, Varun Puri, Stephen Broderick, Daniel Kreisel, A. Sasha Krupnick, G. Alexander Patterson, Bryan Meyers, Traves Crabtree

The authors queried the NCDB to compare outcomes for patients undergoing induction chemotherapy vs chemoradiotherapy followed by resection for esophageal cancer.  The vast majority received chemoradiotherapy (87.5%), which was associated with a better pCR rate and a lower positive margin rate than chemotherapy.   30 and 90-day mortality rates were similar.  In spite of this, there was no difference in overall survival between the groups.

Source: Annals of Thoracic Surgery
Author(s): Todd C. Crawford, MD, J. Trent Magruder, MD, Joshua C. Grimm, MD, Alejandro Suarez-Pierre, MD, Christopher M. Sciortino, MD, Kaushik Mandal, MD, Kenton J. Zehr, MD, John V. Conte, MD, Robert S. Higgins, MD, Duke E. Cameron, MD, Glenn J. Whitman, MD

The Johns Hopkins group reviewed their postoperative complications after heart surgery in 2,477 adult patients from 2011 and 2014 to determine the effect of the number of major complications on the primary outcome of death (as well as several secondary outcomes).  The study found the following rates of mortality by the number of complications:

  • 0 Complications:  0.7% mortality
  • 1 Complication:   4.1% mortality
  • >1 Complication:  41% mortality

Question:  What impact, if any, might the results of this study have on your practice?

 

Source: The New England Journal of Medicine
Author(s): David P. Taggart, Douglas G. Altman, Alastair M. Gray, , Belinda Lees, Stephen Gerry, Umberto Benedetto and Marcus Flather

This editor hastes to submit to JANS this manuscript on the 5 year follow -up of the ART trial. It is guaranteed to be widely cited, probably hotly debated and certainly a disappointment to many of us!

We would not like to pre-empt the ctsnet readers' opinions on this important publication, but we are allowed to comment on the positive findings on skeletonisation, a technique I find has been somewhat controversial, and the methodological disappointment of more than 15 in a 100 subjects randomised to BIMA (BITA) not in fact receiving two arterial grafts!

I personally remember caring, operating and following-up early ART-enrolled patients in Edinburgh Scotland and look forward to the heated discussions this manuscript will immediately generate.

 

 

Source: World Journal for Pediatric and Congenital Heart Surgery
Author(s): Gen Shinohara, Kiyozo Morita, Masato Hoshino, Yoshihiro Ko, Takuro Tsukube,Yukihiro Kaneko, Hiroyuki Morishita, Yoshihiro Oshima, Hironori Matsuhisa, Ryuma Iwaki, Masashi Takahashi, Takaaki Matsuyama, Kazuhiro Hashimoto, and Naoto Yagi

The feasibility of synchrotron radiation-based phase-contrast computed tomography (PCCT) for visualization of the atrioventricular (AV) conduction axis in human whole heart specimens was tested using four post-mortem structurally normal newborn hearts obtained at autopsy. In PCCT images of all four of hearts, the AV conduction axis was distinguished as a low-density structure, which was serially traceable from the compact node to the penetrating bundle within the central fibrous body, and to the branching bundle into the left and right bundle branches. This was verified by histological serial sectioning examination. This is the first demonstration that visualization of the AV conduction axis within human whole heart specimens is feasible with PCCT. This is likely to be a powerful tool for study of the conduction system in the setting of congenital cardiac anomalies.

Source: The Lancet
Author(s): Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sørensen HT, Nielsen PH, Niemelä M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Fröbert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH; NOBLE study investigators.

This is a prospective, randomised, open-label, non-inferiority trial comparing CABG versus PCI in patients with unprotected left main stenosis. The study was carried out at 36 hospitals in Latvia, Estonia, Lithuania, Germany, Norway, Sweden, Finland, the UK, and Denmark.  In total, 1201 patients were randomly assigned, 598 to PCI and 603 to CABG, and 592 in each group entered analysis by intention to treat up to 5 years of follow up. Interestingly, only 8% of the patients in the CABG group had the right internal mammary artery used as a graft (93% had the left ITA used). The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE; death from any cause, non-procedural myocardial infarction,14 repeat revascularisation, or stroke). The key findings of the NOBLE study are that CABG was better than PCI for the composite endpoint of MACCE; all-cause mortality was similar between the two groups; non-procedural myocardial infarction and need for repeat revascularisation were increased after PCI; a higher rate of stroke was observed in the CABG group after 30 days than in the PCI group, but an unexpected, numerically higher rate of stroke was found in PCI-treated patients in 5 year estimates; maximum angina pectoris score was higher after PCI at up to 5 years follow-up.

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