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Journal and News Scan
An institutional registry of ECMO patients was surveyed to determine predictors of survival among patients receiving ECMO in the presence of sepsis. Among 151 studied patients, pneumonia was the most common cause of sepsis. Mortality was predicted by advanced age, longer door-to ECMO times, gram-negative sepsis, and sepsis due to infections other than pneumonia.
In this single institution retrospective study, the relationship of PA pressure to long-term mortality was assessed in patients undergoing unifocalization for pulmonary atresia with VSD. A mean PA intraoperative pressure > 25mm Hg was associated with worse survival, and was the sole predictor of medium-term death.
Valve in valve transcatheter aortic valve implantation (ViV-TAVI) is an alternative to redo surgical aortic valve replacement (SAVR) in inoperable patients and inpatients at high operative risk. This has become even more important now that approximately 80% of all SAVR are bioprostheses and bioprostheses are implanted at younger age. Several TAVI valves have received CE mark and premarket approval for use in degenerated bioprosthesis. This study analysed the effects of design of four different surgical bioprostheses on the hydrodynamic function of an Edwards Sapien XT valve implanted as a ViV-TAVI.
Main findings of this study were:
- Although there was complete coaptation of the leaflets in all 23-mm label-size ViV combinations, there were considerable differences in regurgitation measurements. This means the differences are attributable to paravalvular leakage. The Sapien XT in the Trifecta and the Perimount had the largest paravalvular leakage compared to the Aspire and Mosaic valves.
- The paravalvular leakages are most likely the result of different valve material as the porcine leaflets of the Aspire and the Mosaic are less stiff and provide better seal.
- Surgical valves with externally mounted leaflets (Trifecta) have an increased risk of paravalvular leakage in the ViV combination.
- On the other hand, mean pressure gradient (MPG) was lower in valves with a higher surgical inner diameter (the Perimount and Trifecta valves).
- Higher MPG was the result of underexpansion of the Sapien XT in the Trifecta and Mosaic valves, leading to axial overlap of the leaflets.
This study showed that surgical valves with a large valve area improved hemodynamics for future ViV-TAVI combinations. Moreover, internally mounted leaflets seem to decrease the risk of paravalvular leakage.
Although this is an interesting study, this bench test study was limited to 23mm surgical valves and no calcifications or pannus of the surgical valves were simulated. Use of the valve-in-valve app developed by Dr. Bapat, remains helpful for clinicians making decisions on which TAVI valve is recommended in a specific surgical valve (https://itunes.apple.com/nl/app/valve-in-valve/id655683780?mt=8)
This systematic review of the literature evaluated reported outcomes of myasthenia gravis in patients with and without thymectomy. Among over 10,000 patients evenly divided between thymectomy and medication alone, the likelihood of remission was 31% vs 15%, OR 2.44.
A single institution experience during 22 years for early repair of complete AV canal defects (CAVCD) is reported. Repair was performed in 159 pts between 8 and 12 weeks of age. Operative mortality was 1.9% and later mortality was 7.7%. 13% required reoperation during long-term follow-up, primarily for left AV valve regurgitation. Left AV valve performance at last follow-up was significantly worse in pts older than 3 mons when repaired.
This retrospective single institution study evaluated the relationship between radiation dose to the gastric fundus and the incidence of esophageal anastomotic leak after esophagectomy for cancer. The leak rate was 26%. Pts with a leak had a significantly higher RT dose to the gastric fundus. Using a cut point of 31.4 Gy, leak rates were 43% vs 15% for the high and low dose radiation exposure. Radiation dose was an independent predictor of anastomotic leak in multivariable analysis.
In this retrospective study of propensity-matched patients undergoing CABG, the authors queried whether prior PCI adversely affected outcomes. 9% of over 4500 pts undergoing first time CABG had prior PCI. There was no difference between the groups with regard to hospital mortality or 10-year survival.
The authors queried the NCDB to compare outcomes for patients undergoing induction chemotherapy vs chemoradiotherapy followed by resection for esophageal cancer. The vast majority received chemoradiotherapy (87.5%), which was associated with a better pCR rate and a lower positive margin rate than chemotherapy. 30 and 90-day mortality rates were similar. In spite of this, there was no difference in overall survival between the groups.
The Johns Hopkins group reviewed their postoperative complications after heart surgery in 2,477 adult patients from 2011 and 2014 to determine the effect of the number of major complications on the primary outcome of death (as well as several secondary outcomes). The study found the following rates of mortality by the number of complications:
- 0 Complications: 0.7% mortality
- 1 Complication: 4.1% mortality
- >1 Complication: 41% mortality
Question: What impact, if any, might the results of this study have on your practice?
This editor hastes to submit to JANS this manuscript on the 5 year follow -up of the ART trial. It is guaranteed to be widely cited, probably hotly debated and certainly a disappointment to many of us!
We would not like to pre-empt the ctsnet readers' opinions on this important publication, but we are allowed to comment on the positive findings on skeletonisation, a technique I find has been somewhat controversial, and the methodological disappointment of more than 15 in a 100 subjects randomised to BIMA (BITA) not in fact receiving two arterial grafts!
I personally remember caring, operating and following-up early ART-enrolled patients in Edinburgh Scotland and look forward to the heated discussions this manuscript will immediately generate.