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Journal and News Scan
Schubert and colleagues developed a novel trileaflet mechanical heart valve prosthesis. They compared this device with a conventional mechanical bileaflet heart valve in vitro, evaluating hemodynamic parameters and thrombogenicity. The trileaflet valve had a larger effective orifice area and smaller pressure gradient than the bileaflet one. There were fewer clotting deposits on the trileaflet valve, and the authors pointed to the off-wall systolic position of the hinges in the new valve as a major advantage.
In this statistical primer, Grant and colleagues focus on the use of multivariable regression analyses. The authors review the three most common types of multivariable regression models encountered in the cardiothoracic surgical literature, and they highlight less common models, underscoring the importance of using the correct model for a particular study. They also discuss appropriate approaches for selecting variables and the need to report the model completely so others can reproduce it.
Patient Care and General Interest
The Cardiac Surgery Advanced Life Support (CALS) protocol is expanding to India from the UK, as a cardiac surgical team at Sri Ramachandra Institute of Higher Education and Research in Chennai will become certified CALS trainers.
Drugs and Devices
Edwards Lifesciences has received CE Mark approval for its Pascal transcatheter mitral repair system.
Moves are afoot in the world of robotic bronchoscopy, as Intuitive Surgical receives US Food and Drug Administration approval for its Ion system and Johnson & Johnson acquires Auris Health and its Monarch platform.
CareDx, Inc, announced that the company’s donor derived cell-free DNA test for lung transplant rejection, AlloSure Lung, will be available under a compassionate use program.
Research, Trials, and Funding
Adding acetaminophen to administration of a sedative reduced the incidence and duration of delirium after cardiac surgery, say researchers from Boston, Massachusetts, in JAMA.
Embyronic heart-derived immune cells keep valves slim and in shape, say developmental biologists from the University of California Los Angeles.
Researchers from around the US are advancing computational modeling to predict the postoperative outcome of mitral repairs with presurgical imaging data.
Flynn and colleagues evaluated their center’s implementation of a protocol for extubation within six hours after cardiac surgery, focusing on the rate of adverse events before and after protocol implementation particularly for those patients at highest surgical risk. The authors analyzed prospectively-collected data for patients undergoing cardiac operations within six months of the initiation of the early extubation protocol, 181 patients before and 152 after. They found no differences in the total number of adverse events (renal failure, reintubation, 30-day mortality, or postoperative stroke) before and after the protocol was initiated (16% versus 19%, p = 0.557). In a subset analysis focusing specifically on patients with STS predicted morbidity or mortality score over 40% (8 patients before, 6 patients after the protocol began), the number of adverse events were not different and the median ventilation time was reduced to less than six hours.
The authors conclude that these results are encouraging but merit further investigation, considering the small sample size.
Ishii and colleagues present a narrated video on robotic mitral valve repairs. The lecture includes a detailed description on how to perform safe, reliable, and durable repairs for a range of mitral valve pathologies. The authors discuss an illustrative procedure, performed for a 63-year-old man with severe mitral regurgitation secondary to previous medically-managed infective endocarditis.
This review summarizes the current understanding of the inherited basis for aortic aneurysmal disease and clearly highlights the need to differentiate between thoracic and abdominal aortic manifestations. Approximately 20% of thoracic aortic aneurysms are associated with an autosomal pattern of inheritance from a mutation in a single gene, whereas abdominal aortic aneurysms (AAAs) do not typically demonstrate such inheritance but rather seem to present as a polygenic disorder involving variants of weaker effect. This notwithstanding, there are some distinct biological pathway similarities between thoracic aortic disease (TAD) and AAA; these include the TGF-β and low-density lipoprotein receptor-related protein (LRP1) pathways, as well as other aspects of vascular smooth muscle cell function.
Currently, over a dozen causative genes have been validated for heritable TAD. Each confers a high risk for disease, and genetic testing for these genes is now offered clinically. The situation is far less advanced for AAA, and although polygenic AAA risk scores are being developed, using genetic variants to predict AAAs has not progressed to the extent that it can be used to identify at-risk individuals.
The American College of Cardiology (ACC), the Society for Cardiovascular Angiography and Interventions (SCAI), The Society of Thoracic Surgeons (STS), and the American Association for Thoracic Surgery (AATS), along with key specialty and subspecialty societies, have published a revision of the appropriate use criteria (AUC) for coronary revascularization in patients with stable ischemic heart disease (SIHD). The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.
Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status, risk level as assessed by noninvasive testing, coronary disease burden, and in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria.
A separate independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the middle range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.
As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated.
Patient Care and General Interest
The Donor Alliance observes National Donor Day on February 14th in the US, encouraging people to #StartTheConversation about being an organ donor with their families.
A patient who received a heart-lung transplant shares images of artwork that commemorates both her original and her transplanted organs.
Building on the popularity of the #10YearChallenge, these pictures on the Today Show website highlight successes for patients with congenital heart defects at Children’s Healthcare of Atlanta in Georgia, USA.
Drugs and Devices
Foldax, Inc, was granted investigational device exemption approval from the US Food and Drug Administration for an early feasibility study of their Tria heart valve, which is made from a material the company hopes will provide greater durability.
Research, Trials, and Funding
Researchers from West Virginia Heart and Vascular Institute in the USA find that the rate of emergent percutaneous coronary intervention after coronary artery bypass grafting is 2.6%, higher than was expected.
A new series from the British Medical Journal, NIHR Signals, aims to provide regular summaries of studies with particular relevance to clinical practice. Screening for atrial fibrillation is covered in this week’s summary.
Saran and colleagues sought to evaluate the prevalence of mitral annual calcification (MAC) in patients undergoing valve replacement and to characterize the effect of MAC on postsurgical outcomes. They also discuss their conservative operative approach.
The authors retrospectively analyzed medical records for 496 patients who underwent isolated primary mitral valve replacement at their institution between 2000 and 2015. MAC was present in 115 patients (23%). Although patients with MAC had worse survival than patients without (unadjusted hazard ratio, 1.62; 95% confidence interval 1.20 to 2.18; p = 0.002), the authors conclude that this was due to the prevalence of comorbidities in this group. Multivariable analysis identified risk factors for mortality that included older age, diabetes, dialysis, previous aortic valve surgery, and bioprosthetic valve placement, but not MAC. The incidence of stroke was higher in patients with any mitral calcification, underscoring the importance of thoroughly clearing calcium debris from the surgical field.
Yang and colleagues investigated the use of intestinal flaps for the reconstruction of the cervical esophagus. They reviewed 22 patients with intestinal segments used to salvage failed primary esophagus reconstruction. There was one case of flap failure. The majority of patients did not have any major postoperative complications, and in 21 patients the esophageal continuity and oral intake was successfully restored.