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Journal and News Scan
The Johns Hopkins group reviewed their experience with mediastinal exploration for bleeding after cardiac surgery during the period from 2011 through June 2014, and retrospectively reviewed the outcomes of two categories of patients: (1) Planned Reexploration, defined as patients left open at the initial operation with a plan for a second-look procedure (n=62), and (2) Unplanned Reexploration, defined as those patients who initially underwent sternal closure but required reexploration for bleeding (n=48). Propensity matching generated 30 well-matched pairs for comparison. The primary outcome, operative mortality, was no different between the planned and unplanned reexploration groups, whether propensity-matched (37% v. 37%, p=.47) or not (29% v. 23%, p=.47). The authors conclude that delayed sternal closure with planned reexploration is a safe alternative to initial sternal closure in patients at increased risk for ongoing bleeding.
Comment: After reading this study, would you have a lower threshold for leaving a chest open for bleeding upon completion of a cardiac operation? Why or why not?
It’s well known that VAD and ECMO are associated with bleeding and decreased platelet activity. This study investigated whether loss of platelet receptors occurred in 21 VAD patients and 20 ECMO patients. They found significantly reduced surface receptors (GPIbα and GPVI) in VAD and ECMO patients compared to healthy donors. T he authors concluded that VAD and ECMO may contribute to ablated platelet adhesion/activation and limit thrombus formation under high/pathological shear conditions. Reduced platelet receptors in ECMO patients contribute to the bleeding issues on top of the platelet count reduction.
Balloon aortic valve dilatation has been assumed by some to provide the same outcomes as surgical aortic valvuloplasty. However, the development of precise modern surgical valvuloplasty techniques may result in better
long-term durability of the aortic valve repair. This review of the recent literature suggests that current surgical aortic valvuloplasty techniques provide a safe and durable repair. Furthermore, primary surgical valvuloplasty appears to have greater freedom from re-intervention and aortic valve replacement as compared to balloon aortic valve dilatation.
The presence of a bicuspid valve has been considered as a relative contraindication for transcatheter aortic valve implantation (TAVI). This a multicentre retrospective study of 51 patients with bicuspid aortic stenosis who had undergone TAVI using a next-generation transcatheter heart valve (Edwards SAPIEN 3). 30- day mortality was 3,9%. There were no cases of valve embolization, need for a second prosthesis or annular rupture. Post implantation ballooning was required in 7.8% of the patients. None of the patients had more than mild aortic regurgitation (AR). Mild AR was detected in 37% of the cases. Pacemaker implantation was required in 23,5% of the cases. In this group of patients with bicuspid aortic stenosis, implantation of a new-generation device was associated with minimal paravalvular regurgitation and good clinical outcomes, but a higher than usual need for pacemaker implantation.
The international multicenter CE Mark clinical trial of the HeartMate 3 Left Ventricular Assist System included 50 patients. Thirty-day survival was 98%, bleeding and strokes were observed in 30% and 4%, respectively.
MitraClip therapy for functional mitral regurgitation (MR) was inferior to surgical repair after 4 years with regard to MR recurrence according to a monocenter study on 143 patients who had optimal results immediately after treatment.
4D flow MRI proves markedly altered flow patterns with flow velocity reduction in the LV cavity, especially around the inflow conduit after experimental left ventricular assist device implantation. As an alternative, a newly designed inflow cannula is proposed.
This multistudy registry, entitled ROUTE, studied the effectiveness and safety of transaortic access for TAVI in 301 patients. Mean age was 82 years and mean STS Score 9.0. Valve success was 97%. Total 30-day mortality was 6.1%, and VARC-2 defined endpoints were reported : stroke (1.0%), MI (1.0%), major vascular complications (3.4%), life-threatening bleeding (3.4) and acute kidney injury (9.5%). Moderate or severe paravalvular leak was present in 3.3% of the cases and 8.8% required a pacemaker.
In the accompanying editorial by Thourani et al. it was highlighted non-transfemoral TAVI accounted for almost 50% of the TAVI cases, but with of the current SAPIEN 3 valves the transfemoral route was used in 90% of the cases. The authors stress that transfemoral TAVI will be the mainstay of TAVI treatment and only the minority of patients are likely to undergo non-transfemoral TAVI.
In this retrospective review of 460 consecutive patients undergoing transcatheter aortic valve implantation with the Edwards Sapiens XT or Sapiens 3 prosthesis, the authors analyse the incidence, clinical implications and predisposing factors related to trancatheter heart valve (THV) thrombosis. Of the 460 patients, 405 (88%) underwent multidetector computed tomography in addition to TTE and transesophageal echocardiography (TEE). The incidence of THV thrombosis was 7% (28 of 405 patients). Of these, 5 patients (18%) developed heart failure symptoms during the 12-month follow-up period. The use of a 29 mm THV and no warfarin post-TAVR treatment were independently associated with an increased risk of THV thrombosis. Treatment with warfarin effectively reversed THV thrombosis findings and normalized THV function.
The authors of this study aimed to examine the safety and efficacy of adding ezetimibe to statin in patients with prior CABG following hospitalization for an acute coronary syndrome (ACS).
In total 1684 post CABG patients were studied. The primary endpoint of cardiovascular death, major coronary events and stroke at a median follow-up of six years occured more often in the simvastatine+placebo group as compared to the simvastatine+ezetimibe group (51.2% versus 60.0%; p for interaction=0.02).
This study suggests that adding ezetimibe to simvastatine after ACS in post-CABG patients lowers the risk of cardiovascular events, supporting the use of intensive lipid lowering therapy in these patients.