Journal and News Scan

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.

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.

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.

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.