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Journal and News Scan
Spread through air space (STAS) is a pattern of lung adenocarcinoma invasion, and it is a predictor of recurrence in patients with early-stage lung adenocarcinoma. However, less is known about the role of STAS in advanced lung adenocarcinoma. In this retrospective study including 76 patients with stage III lung adenocarcinoma, the presence of a STAS invasion pattern was a significant risk factor for adenocarcinoma relapse.
Transcatheter aortic valve replacement (TAVR) is expanding to younger patients, but the feasibility of TAVR in failing transcatheter aortic valves (TAV) remains unknown. Dr Tang and colleagues demonstrate in a retrospective review of 551 TAVR procedures by evaluating the postdeployment aortogram using a novel aortic root anatomic classification that TAV-in-TAV after Edwards SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, California) TAVR may not be feasible in >20% of S3 TAVR procedures and in >50% among patients with type 3 roots.
Unique challenges for TAV-in-TAV compared to surgical aortic valve replacement: (1) the native aortic valve leaflets remain in situ after the initial TAVR, acting as a barrier facing the LM orifice; (2) there is currently no predictable way to align the TAV neocommissures with native commissures; (3) often the only way to engage the left main coronary artery is from the TAV stent frame.
This is particularly important given the potential expansion of TAVR to low-risk and/or younger patients who may need redo TAVR. The ascertainment of aortic root type, STJ and SH relative to TVH is essential to guide valve selection and positioning for TAV-in-TAV feasibility on the basis of left main coronary artery obstruction risk.
The Washington University group compared operator radiation exposure during transcatheter valve implantation when performed via a transfemoral versus an alternative access approach, when performed in a catheterization lab versus a hybrid operating room (OR), and investigated the potential benefit of disposable shielding.
They found that procedures performed in the hybrid OR were associated with higher operator radiation exposure. In comparison to the transfemoral approach, alternative access cases had the highest levels of operator radiation. This is particularly important in cases of transcatheter mitral valve replacement that can only be done via an alternative access approach. The use of disposable radiation shielding in this series did not attenuate operator radiation exposure. The authors conclude that radiation shielding within hybrid ORs should be scrutinized in an effort to remain on par with that found within catheterization labs.
Bauser-Heaton and colleagues evaluated outcomes for patients with complex tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries (MAPCAs), focusing on those patients who underwent unifocalization with placement of a shut rather than simultaneous intracardiac repair. Between 2001 and 2017, 57 patients underwent this type of procedure at the authors’ center. In this high-risk cohort, complete repair was achieved in 67% of patients within 3 years. The median right ventricle to systemic pressure ratio for patients with complete repair was 0.4.
Ng and colleagues reviewed articles published between 2000 and 2018 to compare lobectomy approaches of multiport, uniportal, and robotic video-assisted thoracic surgery (VATS) and open lobectomy, with the aim of providing evidence-based recommendations for the optimal surgical approach for early stage non–small cell lung cancer. One hundred and forty-five studies were included in the meta-analysis, which supported the usage of VATS approaches for lobectomy. Multiport VATS was found to have a lower rate of adverse events and less pain than open lobectomy. The different VATS approaches were similar to each other for most outcomes, with uniportal VATS potentially being associated with less pain.
This keynote lecture highlights the need for a standardized prepump intraoperative echocardiology protocol in order to provide a surgeon and their team with a roadmap as to what techniques may be applied for an effective repair of the aortic valve. The authors conclude that such a protocol is essential in enhancing the heart team’s approach by providing a common language between surgeons and echocardiologists, which they hope will ultimately increase aortic valve repairs for select patients in expert centers.
Thoracic stentgrafts are stiffer than the aorta. To understand how this mismatch might affect the left ventricle, van Bakel and colleagues quantified the left ventricular remodeling after thoracic endovascular aortic repair (TEVAR) in 8 patients. They estimated an increase in left ventricular stroke work and found an increase in left ventricular mass after TEVAR. The authors conclude that compliant endografts should be developed to prevent adverse left ventricular remodeling after TEVAR.
Holm and colleagues evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients who were taking P2Y12 inhibitors. Patient outcomes from the European Multicenter Registry on Coronary Artery Bypass Grafting were included in the analysis, with 1,293 patients who received clopidogrel preoperatively and 1,018 who received ticagrelor. The authors observed a higher incidence of major bleeding in patients when these therapies were discontinued for fewer days prior to CABG, and they suggest postponing nonemergent procedures for at least 3 and 4 days after discontinuation of ticagrelor and clopidogrel, respectively.
Rodríguez-Caulo and colleagues report a retrospective multicenter study on almost 1,500 patients aged 50-65 who underwent aortic valve replacement with mechanical or biological prosthesis. The mean length of follow-up was 8 years. There was no significant difference in survival between the valve types. There was a higher rate of major bleeding in patients with mechanical prosthesis; however, reoperation was more frequent among those with a biological prosthesis. The authors conclude that a bioprosthesis in patients of age 55 years and older is a reasonable choice.
Patient Care and General Interest
San Francisco, California, passed an ordinance to ban the sale of e-cigarettes in the city, the first such ordinance in the USA.
The US Centers for Medicare & Medicaid Services (CMS) has released the anticipated update to the national coverage decision for transcatheter aortic valve replacement. The full decision memo is available on the CMS website.
Patient-specific 3D modeling is used to aid planning of a complex chest wall reconstruction.
A brief interview with the chief of cardiothoracic surgery at Phoenix Children’s Hospital in Arizona, USA, focuses on the importance of transparency and a true team attitude to achieve the best possible patient outcomes.
Research, Trials, and Funding
Researchers from Vanderbilt University in Tennessee, USA, report that among adults diagnosed with lung cancer, a smaller proportion of black Americans than white Americans would have qualified for screening.