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Journal and News Scan

Source: European Journal of Cardiothoracic Surgery
Author(s): Moritz Seiffert, Lenard Conradi, Stephan Baldus, Johannes Schirmer, Stefan Blankenberg, Hermann Reichenspurner, Patrick Diemert, and Hendrik Treede

About 3% of 458 TAVI patients required emergent conversion to open surgery with a 30-day mortality of 38.5% in a monocenter analysis. The importance of a interdisciplinary surgical and interventional safety net is emphasized.

Source: YOUTUBE
Author(s): Arie Bitz

A 41 minute presentation on some of the techniques used to address MAC (mitral annular calcification) is followed by an operative video demonstrating several of the techniques. Techniques include mechanical debridement, CUSA debridement, supra-annular MVR, and infra-annular MVR.

Source: Journal of Cardiothoracic and Vascular Anesthesia
Author(s): Joanne Guay

uay J et al. – The study aims to determine major adverse outcomes, including the risk of mediastinal reexploration, death, stroke and myocardial infarction, associated with continuing antiplatelet therapy in patients undergoing surgery with cardiopulmonary bypass. Continuing antiplatelet therapy for patients undergoing surgery with cardiopulmonary bypass (CPB) is associated with a low risk for reexploration.

Methods A meta–analysis of parallel randomized, controlled trials published in English. Patients undergoing surgery with cardiopulmonary bypass (CPB). Continuing antiplatelet therapy versus stopping antiplatelet therapy before the surgery. A search was conducted in PubMed, EMBASE, MEDLINE(R), and the Cochrane Central Register of Controlled Trials. Twelve studies were retained for analysis.

Results Continuing antiplatelet drugs for CPB increases the rate of reexploration by a standardized mean difference (SMD) 0.22, 95% confidence interval (CI) 0.06, 0.39; I–square 0%; p value 0.01; classical fail–safe number 5. The number needed to harm (NNTH) is 87 (95% CI 390, 44). There was no statistical difference for death at 30days and 1year, myocardial infarction at 30days, and stroke at 30days. Continuing antiplatelet drugs increases blood loss, SMD 0.27 (95% CI 0.09, 0.45), I–square 73.1%; p=0.003.

Source: Annals of Thoracic Surgery
Author(s): Marco Ranucci

Dr Ranucci and collegues have analysed data collected about bleeding and transfusion in over 16,000 patients over a 12 year period. Where major bleeding (>900 ml in 12 hrs) occurred, mortality was increased. Other factors associated with mortality included red cell transfusion and preoperative anemia. This is further evidence of the harmful effects of bleeding and its consequences. It supports close attention being paid to factors that can reduce bleeding - stopping drugs associated with bleeding, and use of protocols to determine and manage excessive blood loss and reduce exposure to blood products.

Source: Journal of Thoracic Oncology
Author(s): Farjah, Farhood; Lou, Feiran; Sima, Camelia; Rusch, Valerie W.; Rizk, Nabil P

Prediction of N2 nodal involvement by NSCLC would be valuable in identifying patients who are appropriate for invasive staging.  This study modeled pathologic N2 disease in a cohort of N2 negative patients based on clinical staging.  10% were pathologic N2 largely based on findings at the time of lung resection.  The only predictor of pathologic N2 on multivariate analysis was the presence of N1 disease on PET.

Source: The American journal of cardiology
Author(s): Jeong Hoon Yang

Yang JH et al. – Limited data are available on comparing the clinical outcomes of coronary artery bypass grafting (CABG) and drug–eluting stent (DES) implantation in patients with reduced left ventricular systolic function in the DES era. DES implantation provides comparable long–term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.

Methods

From January 2003 to December 2010, 953 patients with reduced left ventricular systolic function, defined as a left ventricular ejection fraction <50%, who had undergone percutaneous coronary intervention with DESs (n = 402) or CABG (n = 551) were enrolled in a retrospective, observational registry.

After propensity score matching, the long-term cumulative rate of death was not significantly different between the 2 groups (DES vs CABG 21.3% vs 19.1%; adjusted hazard ratio 1.23, 95% confidence interval 0.57 to 2.66, p = 0.603). However, the rate of major adverse cardiac and cerebrovascular events (35.5% vs 24.1%, adjusted hazard ratio 1.69, 95% confidence interval 1.04 to 2.77, p = 0.036) was higher in the DES group than the CABG group. This was driven by the higher incidence of repeat revascularization in the DES group (11.3% vs 4.3%, adjusted hazard ratio 3.65, 95% confidence interval 1.01 to 10.37, p = 0.018). In conclusion, DES implantation provides comparable long-term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.

Source: Journal of the American Medical Association
Author(s): Suri RM, Vanoverschelde JL, Grigioni F, Schaff HV, Tribouilloy C, Avierinos JF, Barbieri A, Pasquet A, Huebner M, Rusinaru D, Russo A,Michelena HI, Enriquez-Sarano M.

In this retrospective study the authors compare the outcomes between early surgery and watchful waiting in a large group of patients with mitral regurgitation due to flail mitral leaflets and without  class I indication for surgery. Those patients who underwent early surgery had lower long term mortality and heart failure risk. There were no differences in the short term outcomes.

Source: Cochrane review
Author(s): Massel DR et al

. – Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimise this risk. An important issue is the effectiveness and safety of the latter strategy. This is an update of our previous review; the goal was to create a valid synthesis of all available, methodologically sound data to further assess the safety and efficacy of combined oral anticoagulant and antiplatelet therapy versus oral anticoagulant monotherapy in patients with prosthetic heart valves. Adding antiplatelet therapy, either dipyridamole or low–dose aspirin, to oral anticoagulation decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is increased with antiplatelet therapy. These results apply to patients with mechanical prosthetic valves or those with biological valves and indicators of high risk such as atrial fibrillation or prior thromboembolic events. The effectiveness and safety of low–dose aspirin (100 mg daily) appears to be similar to higher–dose aspirin and dipyridamole. In general, the quality of the included trials tended to be low, possibly reflecting the era when the majority of the trials were conducted (1970s and 1980s when trial methodology was less advanced).

Source: Heart
Author(s): Raina macintyre

Middle-aged people with hidden heart disease may gain protection from flu vaccination, researchers reveal today.

A study has found that receiving vaccination halves the risk of heart attacks in people over the age of 50 with narrowed arteries.

Australian researchers say their findings may show that flu is a clinically important factor in the risk of heart attack.

Researchers compared 275 patients who suffered a heart attack with another 284 who had not.

The study found no link between suffering flu and having a heart attack - but they did find that being vaccinated was linked to a 45% reduced risk of suffering a heart attack.

Writing in the journal Heart, the researchers call for flu vaccination programmes to be extended to people over the age of 50.

Researcher Professor Raina Macintyre, of the University of New South Wales, Sydney, Australia, writes: "As such, even a small effect of influenza vaccination in preventing heart attacks may have significant population health gains."

Source: The Lancet
Author(s): M Thielmann, E Kottenberg, P Kleinbongard, D Wendt, N Gedik, S Pasa, V Price, K Tsagakis, M Neuhauser, J Peters, H Jakob, G Heusch

Patients undergoing first time CABG using CPB were randomized to remote ischemic preconditioning (left upper arm) or control after induction of anesthetic.  The metric was myocardial injury measured by troponin levels during the first 3 postop days.  Preconditioning resulted in lower troponin levels and in lower operative mortality. 

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