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Journal and News Scan
In the latest issue of JACC, the Stanford group led by Dr. Dake published a retrospective study to evaluate the effectiveness of thoracic endovascular aortic repair (TEVAR) compared to open surgical repair for descending aortic aneurysms.
Among 4580 patients treated between 1999 and 2010, 1,235 patients with open surgical repair patients were matched to 2,470 undergoing TEVAR with follow-up through 2014. The primary endpoint was all-cause mortality, and the secondary endpoint was open or endovascular re-intervention on the descending thoracic aorta. At 180 days, mortality was higher in the surgical repair group (23.8% vs TEVAR 10.2%). Despite a reduced risk for late death (hazard ratio, 0.86, P = 0.004) and reintervention (hazard ratio: 0.40, P < .001) in patients undergoing open surgical repair, the restricted mean survival time difference favored TEVAR, with a difference of -209.2 days (95% CI, -298.7 to -119.7 days; P < .001), revealing a substantial survival advantage with TEVAR at 9 years.
The study concluded that open surgical repair was associated with increased risk of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.
In this paper, Dr Coselli and colleagues analyzed their experience with spinal cord deficit (SCD) after 1114 extent II open thoracoabdominal aortic aneurysm repairs performed from 1991-2017.
The incidence of SCD was 13.6% (151 of 1114), 86 (7.7%) with persistent paraplegia or paraparesis (PPP) (51 paraplegia, 35 paraparesis) and 65 (6.1%) with transient paraplegia or paraparesis. Patients with SCD were older (median 68 versus 65 years old, P<0.001), and they had more rupture (6.6% versus 2.2%, P=0.002) and urgent/emergent repair (25.2% versus 16.8%, P=0.01) than those without. PPP developed immediately in 47 patients (4.2%) and was delayed in 39 (3.5%). Urgent/emergent repair (relative risk ratio [RRR]=2.31, P=0.002), coronary artery disease (RRR=1.80, P=0.01), and chronic symptoms (RRR=1.76, P=0.02) independently predicted PPP. Reattaching intercostal/lumbar arteries (RRR=0.38, P<0.001) and heritable disease (RRR=0.36, P=0.01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without.
This report adds important data to our knowledge of spinal cord deficit after extent II open TAAA repair, which warrants further studies.
This article concludes that five-year survival and morbidity rates in patients over 75 years of age did not differ between off-pump and on-pump groups. The main determinant of poorer long term outcome was incomplete revascularization.
Patient Care and General Interest
Drugs and Devices
Fresenius Medical Care will begin distributing CytoSorbents Coporation’s CytoSorb® blood purification technology in Korea and Mexico, with the aim of serving critically ill and cardiac surgery patients in both countries, pending market registration clearance from the respective local health authorities.
CorMatrix Cardiovascular, Inc, received investigational device exemption from the US Food and Drug Administration for the early feasibility study of their Cor ECM® Tricuspid Valve.
Research, Trials, and Funding
The negative effects of unconscious bias and approaches to work against it were in focus at the recent Annual Meeting of The Society of Thoracic Surgeons in San Diego, California.
Also at January’s STS Annual Meeting, a team from Oregon Health and Science University in Portland presented their experience with intraoperative autologous blood donation in cardiac surgery and a group from Pennsylvania Hospital in Philadelphia presented their efforts to promote on-table extubation after coronary artery bypass.
Researchers from Hokkaido University in Japan have engineered an adenovirus that selectively replicates in cancer cell lines including lung cancer, which they used to suppress tumor cell growth in mice.
In this art of operative techniques segment, Colli and colleagues provide an illustrated description on how to perform transapical NeoChord implantation. The authors’ detailed description includes patient positioning, accurate exposure and important landmarks, and guidance on how to safely maneuver intracardiac instruments under transesophageal echocardiographic guidance.
The European Journal of Vascular and Endovascular Surgery published The European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aortoiliac artery aneurysms. This is an important reference for cardiothoracic and vascular surgeons who are engaged in the care of patients with aortic disease.
The document covers several topics that were not addressed in the 2011 guidelines, including: 1) juxtarenal abdominal aortic aneurysm (AAA), isolated iliac aneurysms, mycotic and inflammatory aneurysms, and concomitant malignant disease; 2) new treatment concepts, such as fenestrated endovascular aneurysm repair (EVAR), chimney EVAR, and endovascular aneurysm sealing; 3) service standards and logistics of importance, including surgical volume requirements and acceptable waiting time for surgery; and 4) the patient's perspective - a topic that is included for the first time in an ESVS guideline.
Several updated recommendations have been made based on new data or evidence for already established topics, including: 1) recommendations on an EVAR-first strategy for ruptured AAA; 2) a stratified, less frequent follow-up regimen after EVAR; and 3) an updated surveillance protocol for small AAAs and subaneurysms.
In the February issue of The Annals, The Society of Thoracic Surgeons published the first annual report after the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) joined the STS National Database in January 2018. This report summarizes the outcomes in patients (≥19 years of age) undergoing durable MCS implant between June 23, 2006, and December 31, 2017.
Among 25,145 patients, 18,539 (74%) received continuous flow left ventricular assist devices (CF LVADs), 667 (2.6%) had a right ventricular assist device (RVAD) with CF LVAD, 339 (1.3%) received a total artificial heart, and 20 (0.07%) received an isolated RVAD. Of the CF LVADs, mean age was 57 ± 1 years, 26% were listed for transplantation, and 51% were in cardiogenic shock (profile 1 to 2) preoperatively. CF LVADs included 14,527 axial flow (78%) and 4,012 centrifugal flow (22%) devices. Recently (2012-2016), more patients are in Intermacs profile 3, with better renal and hepatic function, and received implants for destination therapy (48%), with a centrifugal flow device (51%).
Mean CF LVAD support duration was 20 months. Survival for isolated CF LVADs was 83% at 1 year and 46% at 5 years. One-year survivals for centrifugal versus axial flow devices were 85% and 84%, respectively. Patients with concomitant RVAD support had 1-year and 5-year survivals of 58% and 28%, respectively. Freedom from all-cause readmission was 70% at 1 month and 20% at 1 year. At 1 year, stroke occurred in 20% with centrifugal flow and 13% with axial flow support (p < 0.001), gastrointestinal bleeding affected 20% with centrifugal flow devices and 25% with axial flow devices (p < 0.001), and pump-related infection occurred in 28% of patients with centrifugal flow devices versus 25% with axial flow devices (p = 0.01). Neurologic dysfunction (19% of deaths) and multisystem organ dysfunction (15%) were the most common causes of death.
Park and colleagues evaluated the effect of neoadjuvant chemotherapy for thymic cancers, comparing postoperative outcomes and long-term survival between 102 matched pairs of patients who underwent either upfront resection or resection after neoadjuvant chemotherapy. Postoperative complications and hospital length of stay were similar between the groups, as were three-year recurrence-free survival and five-year overall survival.
On February 4, 2019, Cook Medical announced recent approval from the US Food and Drug Administration for its Zenith Dissection Endovascular System. The system consists of a proximal stent-graft component and a distal bare stent component. It provides a less invasive alternative to open surgery for repair of type B dissections. The device will be available for sale in the United States in the coming months.
In this prospective single-institution study, functional status trajectory one year after intervention was compared for transcatheter (TAVR) versus surgical aortic valve replacement (SAVR). A moderate/large decline compared to preintervention status occurred in 23% of TAVR patients and 4% of SAVR patients. A frailty index, postoperative delirium, and procedure-related complications were associated with postintervention decline.