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Journal and News Scan

Source: Annals of Thoracic Surgery
Author(s): Paul J Speicher, Zachary W Fitch, Brian C Gulack, Chi-Fu J Yang, Betty C Tong, David H Harpole, Thomas A D'Amico, Mark F Berry, and Matthew G Hartwig

The authors tested the hypothesis that induction therapy improves survival in patients undergoing resection for clinical N1 disease using information from the National Cancer Data Base.  10% of over 5,000 pts were treated with induction therapy.  They were 2:1 propensity matched with patients undergoing the traditional surgery first strategy.  Among surgery first patients, 16% were overstaged (pN0) and 11% were understaged (pN2-3).   There was no difference in short-term outcomes or survival between the two treatment groups.

Source: Annals of Thoracic Surgery
Author(s): The International Cardiac Collaborative on Neurodevelopment (ICCON) Investigators

Operative and postoperative factors' relationship to intermediate term neurodevelopment were assessed in patients who underwent cardiac surgery on bypass at age 9 mos or less using the Psychomotor Development Index (PMI) and the Mental Development Index (MDI).  Lower PDI and MDI were associated with longer interoperative support time, with use of ECMO or VAD, and with longer postoperative length of stay.  After adjusting for patient, preoperative, operative, and postoperative factors, the operative and postoperative factors accounted for only 5% of the variance, suggesting that preoperative and patient factors have the most impact on postoperative neurodevelopment.

Source: Annals of Thoracic Surgery
Author(s): Alison M. Pouch, Benjamin M. Jackson, Eric Lai, Manabu Takebe, Sijie Tian, Albert T. Cheung, Y. Joseph Woo, Prakash A. Patel, Hongzhi Wang, Paul A. Yushkevich, Robert C. Gorman, Joseph H. Gorman

The authors evaluated the accuracy of a semi-automated method of developing 3D images of mitral valve disease, generated from 3D echocardiograms, in clinical decision making.  Resulting images were very similar to images created through laborious analysis by hand of echo results, and were dissimilar to images of normal mitral valves.  The clinical utility of this technology will need to be assessed.

Source: Annals of Thoracic Surgery
Author(s): John P Nabagiez, Masood A Shariff, William J Molloy, Seleshi Demissie, Joseph T McGinn Jr.

The utility of a home visit program for patients discharged to home after cardiac surgery was assessed comparing a 4 year cohort of home visit patients to patients operated prior to the home visit program initiation.  Home visits decreased readmission rates by about 40%.  Costs per readmission were $40,000 to $56,000, whereas the cost of the entire program for 363 pts was only $25,000. This translated to a 2-year savings of nearly $1 million, and $39 in savings for each $1 invested.

Source: Annals of Thoracic Surgery
Author(s): Matthew L. Williams, MD, Joseph E. Bavaria, MD, Michael A. Acker, MD, Nimesh D. Desai, MD, Prashanth Vallabhajosyula, MD, W. Clark Hargrove, MD, Pavan Atluri, MD, Wilson Y. Szeto, MD

This single-center retrospective study evaluated outcomes of ESRD patients undergoing valve surgery based on whether they received either a mechanical or tissue valve.  The study spanned the years 2002-2014, and included 64 mechanical and 151 tissue valve replacements.  Even after controlling for confounding variables--given the short expected survival in these patients--there is no salutary effect of using a mechanical over a tissue valve.  

Comment:  Given the morbidity of anticoagulation in, and the shorter lifespan of, ESRD patients, should we be using mechanical valves at all in these patients?

Source: Annals of Thoracic Surgery
Author(s): John P. Nabagiez, MD, Masood A. Shariff, MD, William J. Molloy, PA-C, MPH, Seleshi Demissie, DrPH, Joseph T. McGinn Jr., MD

This retrospective study analyzed the relative cost-effectiveness of a physician assistant home care (PAHC) program in terms of readmission rates, length of stay, and health care cost.  The study hospital switched from a conventional discharge treatment plan (control) in September 2010 to a PAHC program.  A total of 1,185 patients who were discharged home after cardiovascular surgery were included in the analysis.

The authors found the following:

  • Readmission rates decreased by 41% for propensity-matched patients.
  • There was no signifiant difference in LOS.
  • Institution of the PAHC program saved $39 for every incremental dollar spent on the program.  

Comment:  Accordingly, this single center study suggests that the institution of a PA (or NP) home visit program may be extremely cost-effective.  This is a strategy that may make a great deal of sense of bundling of payments for cardiovascular services becomes mainstream.


Source: New England Journal of Medicine
Author(s): Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Ströbel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BR, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Garcia Ramos GS, Verschuuren JJ, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Conwit R, Odenkirchen J, Sonett JR, Jaretzki A 3rd, Newsom-Davis J, Cutter GR; MGTX Study Group.

A small international prospective randomized trial of extended thymectomy with steroids vs steroids for 126 with class II to IV myasthenia gravis.  The selection criteria and powering were altered mid-trial. Surgery was associated with a better symptom score, lower dose of predisone, less use of immunosuppresives, and fewer hospitalizations at 3 years.  The positive outcomes are of surgical relevance as they may lead to a considerable increase of referrals for OPEN thymectomies! I assume that longer term outcomes will be forthcoming.

Source: Journal of the American Medical Association
Author(s): Stephan Haussig; Norman Mangner; Michael G. Dwyer; Lukas Lehmkuhl; Christian Lücke; Felix Woitek; David M. Holzhey; Friedrich W Mohr; Matthias Gutberlet; Robert Zivadinov; Gerhard Schuler; Axel Linke

In this study the investigators aimed to study whether a cerebral protection device during TAVI reduced the number of cerebral lesions in patients undergoing TAVI.

In total, 100 patients undergoing TAVI between April 2013 and June 2014 were randomized to either the filter or control group. The number of new lesions at 2 days after TAVI, as measured by diffusion-weighted magnetic resonance imaging (DWMRI), was lower in the filger group (4.00 versus 10.00 in the control group, p<0.001). Also lesion volume was lower in the filter group. Adverse events were similar in the filter and control group.

This small randomized study shows that a cerebral protection device reduced the frequency of ischemic cerebral lesions after TAVI. Further larger studies are needed to assess the beneficial effect on neurological and cognitive functioning. 

Source: Perfusion. 2016 Jul 21
Author(s): Guajardo Salinas GE, Nutt R, Rodriguez-Araujo G.

This is a retrospective study comparing outcomes of conventional 1:4 cardioplegia vs 4:1 Del Nido cardioplegia on adult patients undergoing CABG. 249 consecutive patients underwent coronary artery bypass using blood cardioplegia and 159 using del Nido Cardioplegia. Authors found no significances in CPB time, X-clamp time, in-hospital mortality or length of stay between these two groups.  However, they found that patients with Del Nido had less defibrillation need, less blood transfusion rate and transfusion volume, as well as less Hgb change. Most patients had spontaneous return of sinus rhythm.

Source: Journal of Thoracic and Cardiovascular Surgery
Author(s): Kannan RY

A bona fide new technique applied in a handful of low-risk deep sternal wound infections. It will be interesting to see the follow-up and perhaps some cardiothoracic surgical input to the efforts of the esteemed plastic surgical colleague who is the sole author.