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Journal and News Scan
Raja and colleagues evaluated the return of symptoms and rate of reintervention following Heller myotomy for achalasia. Over a seven-year period, 248 patients underwent Heller myotomy. The majority of patients, 69%, experienced the return of at least one symptom during the follow-up period (median follow-up of 36 months), and 50 patients underwent 85 reinterventions. The majority of reinterventions were done endoscopically, and five-year freedom from reintervention was lowest for patients with type I achalasia. The authors conclude that it is important for patients to understand that Heller myotomy will likely only palliate achalasia symptoms, and they recommend lifelong postprocedural surveillance.
Andreas and colleagues report their experience of aortic valve replacement with rapid-deployment surgical aortic valves prostheses in 500 patients over seven years. The authors found a 0.8% 30-day mortality, and the valves showed excellent hemodynamic performance, durability, and safety with a median follow-up time of 12 months. Minimally invasive access was achieved in 47% of patients.
To date, there has been no unianimous method to calculate the diameter of the aorta prior to the occurence of type A aortic dissection. In this study, reseachers from Osaka, Japan, reported the efforts in developing equations for estimating the predissection diameters of the ascending aorta and the arch based on postdissection measurements. These equations have the potential of determining the size of stent grafts in the management of patients with type A dissection.
Endospan announced that it has received European CE Mark approval for its Nexus stent graft system for the endovascular repair of aortic arch disease comprising both aneurysms and dissections.
Nexus is a low-profile branched stent-graft designed and engineered specifically for the aortic arch to allow ease of deployment while achieving a durable effective repair and importantly minimizing the risk of stroke and other cardiovascular complications. It represents a major milestone, being the first low-profile branched endovascular stent-graft to be available off-the-shelf in Europe for endovascular repair of the aortic arch, especially for high-risk partients with complex arch pathologies.
Researchers of the Canadian Thoracic Aortic Collaborative (CTAC) analyzed the operative outcomes in 1653 patients (30% women) undergoing thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite (STS-COMP) for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation).
Compared with men, women were older (66 versus 61 years; P < 0.001) and had more hypertension and renal failure, but they had less coronary disease, less previous cardiac surgery, and higher ejection fractions. Rates of aortic dissection were similar between two genders, as were rates of hemiarch, total arch, and thoracoabdominal aortic repair. However, women had less aortic root reconstruction, including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P < 0.001). Men had longer cross-clamp and cardiopulmonary bypass times than women, but they had similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women had a higher rate of death (11% versus 7.4%; P = 0.02), stroke (8.8% versus 5.5%; P = 0.01), and STS-COMP (31% versus 27%; P = 0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio [OR], 1.81; P < 0.001), stroke (OR, 1.90; P < 0.001), and STS-COMP (OR, 1.40; P < 0.001).
Given the worse outcomes in women, the authors call for earlier surgery once diagnosis of thoracic aortic disease is made in women and further investigation to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.
Yanagawa and colleagues evaluated the experience of 10 centers in Ontario, Canada, participating in the Ontario Transfusion Coordinator (ONTraC) program to determine if red blood cell transfusion rates were reduced by patient participation in the program and optimization of hemoglobin prior to coronary artery bypass grafting (CABG). The authors discuss the ONTraC program, noting that the first 60 consecutive patients undergoing CABG at each center each year were referred for assessment. After this, patients were referred only upon physician request. Over the 10 years following the start of the program, overall transfusion rates fell from 40.1% to 26.2%. Patients who were assessed by an ONTraC coordinator were more likely to be older, to be women, and to be anemic, but despite this, no differences were found in overall transfusion rates between patients who were and were not assessed. When patients were stratified by World Health Organization Anemia Classification, patients with both mild and moderate-to-severe anemia who were assessed prior to CABG had lower transfusion rates than patients with anemia who were not assessed.
Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available.
In this study, the vascular team from NYU Langone Hospital in Brooklyn, New York, retrospectively analyzed their experience in 18 patients who underwent D-TEVAR between March 2014 and January 2018. No major complications occurred. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support.
Although these data suggest that cardiothoracic surgery support is not required D-TEVAR, the conclusion should be interpreted very cautiously. The importance of multidisciplinary collaboration in treating patients with aortic disease cannot be overemphasized.
This review summarizes recent promising applications of artificial intelligence (AI) in cardiology and cardiac imaging, which potentially add value to patient care.
Problems with timing, efficiency, and missed diagnoses occur at all stages of the imaging chain. The application of AI may reduce cost and improve value at all stages of image acquisition, interpretation, and decision-making. The main fields of AI for imaging will pertain to disease phenotyping, diagnostic support, and image interpretation. Grouping of relevant clinical and imaging information with cluster analysis may provide opportunities to better characterize disease. Diagnostic support will be provided by automated image segmentation and automated measurements. The initial steps are being taken towards automated image acquisition and analysis. “Big data” from imaging will interface with high volumes of data from the electronic health record and pathology to provide new insights and opportunities to personalize therapy.
A number of interesting findings in early follow up of this randomized controlled trial on one type of transcatheter aortic valve against conventional surgery: the mechanics of the valve and the incidence of complete heart block, to name but a few. We await the longer follow up.
The American College of Cardiology's 68th Annual Scientific Session has released the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. This guideline includes newly generated recommendations for control of blood presssure, cholesterol and type II diabetes, aspirin use, regular exercise and physical activity, heathier diet, and tobacco use, in addition to recommendations related to team-based care, shared decision-making, and assessment of social determinants of health, to create a comprehensive yet targeted ACC/AHA guideline on the prevention of atherosclertoic cardiovascular disease.