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Journal and News Scan
This well documented report analyses different techniques for Bentall procedures performed using biological valved conduit, which have dramatically expanded mainly due to the increased incidence of aortic disease in the aging population, many patients not being amenable to aortic valve repair. Authors offer detailed, well documented description of techniques to be used when performing this procedure with Medtronic Freestyle Root Vascutek BioValsalva graft, Sorin Mitroflow Valsalva graft, and so-called hand-sewn biological composite graft.
Coronary artery bypass grafting versus drug-eluting stents in patients with severe coronary artery disease and diabetes mellitus: a systematic review and meta-analysis
Journal of Diabetes, 06/11/2014 Evidence Based Medicine Review Article
The authors performed a comprehensive meta–analysis to evaluate the comparative benefits of coronary artery bypass grafting versus drug–eluting stents in patients with diabetes mellitus and severe coronary artery disease. For patients with diabetes mellitus and severe coronary artery disease, CABG was superior to DES in that it significantly improve overall and MACCE–free survival rate and reduce incidences of myocardial infarction and repeat revascularization in the long–term follow–up, although it was associated with more perioperative risks and a higher incidence of stroke. Therefore, CABG should remain the gold standard for these patients.
- A comprehensive literature search of PubMed, Embase, and ScienceDirect was carried out.
- References and cited papers of relevant articles were also checked.
- A total of 4 randomized controlled trials, 2 prospective registries and 11 retrospective studies were identified for this review.
- Pooled analysis demonstrated that DES was associated with lower all-cause mortality at 30-day.
- However, there was no significant difference between CABG and DES in mortality at 12-month and at maximum follow-up, DES was associated with lower overall and MACCE-free survival rate, higher incidences of myocardial infarction and repeat revascularization.
- CABG was associated with an increased risk of stroke.
Using data from the Australian Cardiac Surgical Database, the authors provide further information regarding acute kidney damage after cardiac surgery. This study has added to the evidence that preoperative impairment, IABP use, red cell transfusion and infective endocarditis are predictive factors. It remains to be determined what therapies can be instituted to reduce changes in renal function in future clinical trials.
The rate of cerebral embolism in patients with acute infective endocarditis (AIE) was about one quarter on CT scanning, with about one third having silent emboli. This had an adverse impact on survival. Haemorrhagic transformation was low. The authors indicate CT scanning should be routine for all patients with AIE.
This is one of the excellent videos available free in full at www.annalscts.com
Massive left hemothorax is a rare and dramatic complication of acute type B aortic dissection. The primary endpoint is to treat the aortic rupture, stop the bleeding and stabilize the hemodynamic status, with the aim to prevent mortality and major cardiac, cerebral, visceral and renal complications. Thoracic endovascular repair (TEVAR) is the most frequent management, although its planning, in these emergent patients, may be very difficult and sub-optimal imaging may result at post-operative examination (CT and MRI). In case of TEVAR is not the definitive treatment of the aortic disease, a second stage surgical management can be performed in elective status, in a patient with a total clinical recover. In acute and dramatic circumstances, like ruptured type B dissection, TEVAR is a valid and suitable bridge procedure to open surgery, reducing the overall risk for mortality and major complications.
This report on 127 pts with atypical pulmonary carcinoid evaluated clinical and pathological prognostic features. Recurrence developed in 25% of pts during follow-up, with sublobar resection being the only independent predictor. Survival was related only to distant recurrence on multivariable analysis. The authors recommend complete standard anatomical resection with radical lymphadenectomy as a the standard of care.
In this study, the authors identify a number of markers in cardiac stem cells obtained from 38 patients undergoing coronary artery bypass grafting which appear to predict positive myocardial remodelling at 12 months following surgery
This large-scale study evaluated kidney function postoperatively and at 1 year after either on-pump or off-pump isolated first time CABG. Nearly 3000 pts were enrolled over a 2 year period. Outcomes were a >50% increase in creatinine within 30 days of operation (AKI) and >20% loss of GFR at 1 year. Off-pump bypass was associated with a lower incidence of AKI (17.5% vs 20.8%), but the rates of loss of kidney function at 1 year were similar (17.1% vs 15.3%).
Coronary artery bypass grafting (CABG) has been considered the standard of care for patients with three-vessel disease (3VD), but long-term comparative results from randomized trials of CABG vs. percutaneous coronary intervention (PCI) using drug-eluting stents (DES) remain limited. Five-year results of patients with 3VD treated with CABG or PCI using the first-generation paclitaxel-eluting DES suggest that CABG should remain the standard of care as it resulted in significantly lower rates of death, MI, and repeat revascularization, while stroke rates were similar. For patients with low SYNTAX scores, PCI is an acceptable revascularization strategy, although at a price of significantly higher rates of repeat revascularization.
- Patients with de novo 3VD or left main disease were randomly assigned to PCI with the paclitaxel-eluting first-generation stent or CABG in the SYNTAX trial.
- This pre-specified analysis presents the 5-year outcomes of patients with 3VD (n = 1095).
- The rate of major adverse cardiac and cerebrovascular events (MACCE) was significantly higher in patients with PCI compared with CABG (37.5 vs. 24.2%, respectively; P < 0.001).
- Percutaneous coronary intervention as opposed to CABG resulted in significantly higher rates of the composite of death/stroke/myocardial infarction (MI) (22.0 vs. 14.0%, respectively; P < 0.001), all-cause death (14.6 vs. 9.2%, respectively; P = 0.006), MI (9.2 vs. 4.0%, respectively; P = 0.001), and repeat revascularization (25.4 vs. 12.6%, respectively; P < 0.001); however, stroke was similar between groups at 5 years (3.0 vs. 3.5%, respectively; P = 0.66).
- Results were dependent on lesion complexity (P for interaction = 0.12); in patients with a low (0–22) SYNTAX score, PCI vs. CABG resulted in similar rates of MACCE (33.3% vs. 26.8%, respectively; P = 0.21) but significantly more repeat revascularization (25.4% vs. 12.6%, respectively; P = 0.038), while in intermediate (23–32) or high (≥33) SYNTAX score terciles, CABG demonstrated clear superiority in terms of MACCE, death, MI, and repeat revascularization.
- Differences in MACCE between PCI and CABG were larger in diabetics [hazard ratio (HR) = 2.30] than non-diabetics (HR = 1.51), although the P for interaction failed to reach significance for MACCE (P for interaction = 0.095) or any of the other endpoints.
The authors of this paper prospectively studied stroke after aortic valve replacement (AVR) in patients with aortic stenosis (AS) and >65years old. Neurological status was assessed pre- and postoperatively assessed by neurologists, postoperatively by MRI and strokes were evaluated according to the National Institutes of Health Stroke Sscale. The authors show that the incidence of clinical stroke after AVR was higher than for the same cohort in the STS database. Moreover, sub-clinical infarctions were detected in >50% of all AVRs. Clinical stroke was associated with longer hospital stay and higher mortality.