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Journal and News Scan
Why this study – the rationale/objective
This study compared the volumes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) since the approval of TAVR in the United States. The Medicare Provider Analysis and Review (MEDPAR) database was used to extract volumes for 2011-2014. The volume of SAVR decreased in hospitals with the largest number of TAVR procedures. At the same time, 30-day and 1-year mortality after SAVR declined in the hospitals with the largest TAVR volumes. Patients who underwent SAVR showed a decrease in comorbidities over time. The study provides some interesting insights. First, the large number of excluded centers highlight the large amount of centers in the US that perform very few aortic valve procedures. Second, the lower mortality after SAVR and low risk profile of SAVR patients was likely the result of high risk patients getting TAVR. Third, the current study does not include data from recent years. It will be very interesting to learn whether the increasing TAVR volume leads to a decrease in SAVR volume, especially since results of TAVR vs. SAVR in low risk patients are expected shortly.
The authors of this study analyzed neurological events and quality-of-life in the Surgical Replacement and Transcatheter Aortic Valve Implantation (SURTAVI) trial. A total of 1746 patients with aortic stenosis and intermediate surgical risk were randomized to either TAVI or SAVR. Neurological events and quality of life were analyzed at 30 days, six months, and 12 months. In this group of elderly (approximately 80 years old) patients with an intermediate risk profile (STS-PROM 4.5), the event rates at 30 days were higher for SAVR as compared with TAVI for both stroke and encephalopathy (5.4% vs. 3.3%, p=0.031 and 7.8% vs. 1.6%; p<0.0001, respectively). There were no differences in the incidence of late strokes (TAVI 2.0% vs. SAVR 1.5%). Neurological events were associated with increased mortality at one year. Quality of life after an early stroke in TAVI patients was higher than in SAVR patients who suffered from a stroke. The thoroughness and consistency in stroke assessment in this trial is a major strength. Whereas the early PARTNER IA trial showed a higher stroke rate with TAVI than with SAVR (4.7% vs. 2.4% respectively), these results show a more favorable outcome for strokes after TAVI. Interestingly, no embolic protection devices were used in the trial. Application of these devices is now more and more common and might further reduce stroke rate after TAVI. The results of this study provide further evidence supporting TAVI in intermediate risk patients.
This study addressed the question of utilization of limited resources, specifically whether ill or low weight infants should be listed for transplant based on survival. Among patients in the United Network for Organ Sharing database, very low weight was associated with worse one year survival, and being on ventilator or extracorporeal membrane oxygenation support carried additional negative effects on survival.
Direct relief of subaortic stenosis in single ventricle patients via ventricular septal defect/subaortic chamber enlargement has been mostly replaced by the Damus-Kaye-Stansel/Norwood procedure due to concerns for potential re-obstruction or heart block. However, little is known about long-term outcome. Among 23 single ventricle patients (median age: 7.4 months, range: 10 days to 5.5 years) who underwent direct relief of subaortic stenosis at Leiden University Medical Center (1989-2016), authors observed a high risk of re-obstruction and patch (pseudo)aneurysm formation. However, risk of heart block was low, and the majority of patients underwent Fontan completion successfully. In selected patients, the direct approach can be a relatively simple and safe procedure.
Aortic dissection frequently occurs in patients with normal aortic diameter. The authors indexed aortic area to height and correlated with absolute aortic diameter. Using this new index, they were able to identify a significant proportion of patients with thoracic aortic aneurysms who were at increased risk of aortic complications.
Patient Care and General Interest
A 5-year-old boy in Sacramento, California, USA, who has a congenital heart defect and has undergone four related heart surgeries, has had his wish of becoming a Ghostbuster fulfilled.
A study published in The BMJ suggests that a group of common blood pressure drugs may be linked to lung cancer.
Drugs and Devices
A study published via the Proceedings of the National Academy of Sciences of the United States of America indicates that wearable technology could potentially monitor the relationship between blood pressure and pulse wave velocity in arteries, possibly helping patients monitor high blood pressure.
According to a study published in the Journal of the American College of Cardiology, an electrocardiogram reading from a specially equipped Apple Watch could potentially prove highly effective in detecting atrial fibrillation.
Research, Trials, and Funding
The Northern New England Biomarker Study suggests that elevated preoperative Galectin-3 is associated with acute kidney injury after cardiac surgery.
Researchers at the University College London’s Great Ormond Street Institute of Child Health in the UK have successfully grown a functional esophagus from stem cells and transplanted it in mice.
The authors measured the risk of obstructive sleep apnea (OSA) preoperatively in patients undergoing thoracic surgery using the “STOP-BANG” questionnaire. A total of 76% of patients were considered intermediate to high risk for OSA, and this group had a longer duration of ICU delirium/coma than the low risk group.
A post-market study (ELEVATE registry) of the fully magnetically levitated continuous flow HeartMate III left ventricular assist device (LVAD) found no pump thrombosis in 463 patients in Europe and Kazakhstan.
Mean age was 55.6 ± 11.7 years, 89% were male, 48% had ischaemic aetiology, and 70% were on inotropes. Indication was bridge-to-transplantation in 66% and destination therapy in 26%. Mean left ventricular ejection fraction was 18.3% and INTERMACS profile was 1–2 in 32%.
In 463 patients, there was no incidence of pump thrombosis; major bleeding was 25%, major infection 35%, and any stroke type 5%. Functional capacity improved significantly (Δ6MWD 230 ± 191 m), as did quality of life (ΔVAS 31 ± 23). Survival at six months was 82 ± 2%. Freedom from unplanned rehospitalizations at six months was 68 ± 2%.
This potential to reduce haemocompatibility-related events is one of the main improvements of HeartMate III over other LVADs.
Farhood Saremi and colleagues from the University of Southern California contributed a comprehensive review of the computed tomography angiographic (CTA) findings that improve the accuracy of diagnosis of thoracic aortic dissection and predict the outcomes of different management strategies for this highly lethal disease. The authors present the concept of aortic remodeling and the spectrum of CTA findings with regard to favorable or failing remodeling. This review also summarizes important image findings that are predictive of positive or negative remodeling before and after thoracic endovascular aortic repair. Knowledge of these imaging findings and their inclusion in a concise radiology report are important for optimum patient care.
Kim and colleagues sought to determine if a supra-annular aortic valve prosthesis implantation is superior to an intra-annular implantation. The authors retrospectively reviewed outcomes and echocardiographic data for 587 patients who received either supra-annular or intra-annular aortic valve prostheses from St Jude Medical. The implantation technique did not significantly affect the risk of overall mortality or major adverse events, however there were superior hemodynamics with lower peak velocity, lower mean pressure gradient, and improved ventricular mass index in patients with supra-annular implantation.