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Journal and News Scan
In this systemic review and meta-analysis, the authors compared outcomes for patients undergoing aortic root replacement to those undergoing a David operation. Mosbahi and colleagues analyzed 27 studies that included a total of 3058 patients with acute type A aortic dissections. In-hospital mortality and midterm survival both favored aortic valve reimplantation. Freedom from valve-related reintervention was 100% (confidence interval (CI) 93.7 - 100%) in patients who underwent reimplantation compared to 94.6% (CI 86.7 - 99.1%) for a composite valve graft intervention. The authors conclude that in type A dissection the reimplantation procedure (David operation) provided a superior outcome.
The Arterial Revascularization Trial Investigators recently published the outcomes of coronary artery bypass grafting (CABG) using bliateral versus single internal thoracic artery (ITA) after 10 years. Patients were randomly assigned to CABG using the bliateral or single ITA. The primary outcome was death from any cause at 10-year follow-up. Secondary outcomes were the composite of death from any cause, myocardial infarction, or stroke, rate of repeat revascularization, and safety outcomes. At 10 years, death occurred in 644 patients (20.8%), with 315 deaths (20.3%) occurring in the bilateral ITA group versus 329 (21.2%) in the single-graft group (P=0.62). The number of secondary events was 385 (24.9%) in the bilateral ITA versus 425 (27.3%) in the single ITA group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). No significant differences were found between the two groups in the rate of death from any cause or the rate of the composite outcome of death, myocardial infarction, or stroke. Further studies are needed to determine whether multiple arterial grafts can provide better outcomes than a single ITA graft.
In a letter to healthcare providers, the US FDA summarized a recent evaluation of a postapproval study of the Abiomed Impella RP system. In clinical trials, 73% of patients survived 30 days after device explant, hospital discharge, or to definitive intervention. In the postapproval study, just over 17% of patients met this goal. There is some evidence to suggest that patients in the postapproval study were suboptimal candidates for the system.
In this retrospective cohort study, Dr Ehrlich and his colleagues reported excellent early and long-term results of thoracic endovascular aortic repair (TEVAR) for 55 high-risk patients with life-threatening acute complicated type B aortic dissection. The mean age of patients was 52 ± 13 years. The indications for TEVAR included malperfusion (58%), aortic rupture (18%), or persistent untreatable pain with true lumen reduction or rapid aortic diameter enlargement (24%). The technical success was 91% and overall in-hospital mortality rate was 9%. At 5 years, survival was 75%, with 77% freedom from aorta-related death and 63% freedom from reintervention.
Patient Care and General Interest
Former Indian Prime Minister Manmohan Singh chimes in to the #10YearChallenge with a focus on his heart surgery.
A New England Journal of Medicine case report on trachealization of the esophagus made headlines, describing a patient who had sought care after getting a pizza roll stuck in his throat.
An update to the 2014 US guidelines on managing patients with atrial fibrillation was issued by the American Heart Association, the American College of Cardiology, and the Heart Rhythm Society.
Research, Trials, and Funding
Cell-free DNA might be useful to monitor patients with transplanted lungs for transplant rejection, say researchers from the US National Heart, Lung, and Blood Institute.
A partnership between space technology company Techshot and NASA aims to study cardiac tissue growth in zero gravity.
Research presented at the recent Society of Thoracic Surgeons’ Annual Meeting in San Diego, California, suggests that cardiac surgery outcomes in the US are similar at the beginning and the end of the academic training year.
Martin and colleagues describe two efforts to improve outcomes within the congenital heart disease field: the Improving Pediatric and Adult Congenital Treatments (IMPACT) Registry and the National Pediatric Cardiology-Quality Improvement Collaborative (NPC-QIC). The authors discuss some of the insights that have been gained using data from the IMPACT Registry and outcome improvements that have resulted from the collaborative structure of the NPC-QIC. They emphasize the importance of both registries and learning collaboratives to ensure that best practices are both identified and implemented.
Vitanova and colleagues reviewed outcomes of systemic-to-pulmonary artery shunt surgery to identify potential risk factors for negative outcomes in neonates. Between 2000 and 2016, 305 shunts were implanted in 280 newborns, with a median age of 9 days old. Shunt failure occurred in 8% of patients, and shunt-related mortality was 4%. Univariate analysis determined perioperative platelet transfusion, central shunt, shunt size of 3 mm, and postoperative extra corporeal membrane oxygenation to be risk factors for shunt failure.
Hata and colleagues performed a propensity score-matched analysis comparing 85 pairs of patients who underwent either minimally invasive mitral valve repair or chordal-sparing replacement for degenerative mitral valve regurgitation. Freedom from major adverse cardiac and cerebrovascular events after seven years was similar between the groups. There was no difference in mortality and no difference in freedom from valve reintervention.
Garbade and colleagues compared outcomes reported during the European Conformity (CE) Mark clinical trial of the HeartMate 3 left ventricular assist device (LVAD) to outcomes for patients treated since the device came to market. Patients treated after device approval, from the ELEVATE registry, were more severely ill, were older, and underwent more concomitant valve procedures than those treated in the CE Mark trial. After adjusting for baseline differences between the groups, the authors found comparable 30-day survival. Rates of bleeding, infection, and stroke were also similar between the two groups, and no instances of pump thrombosis were recorded.
Malvindi and colleagues assessed the outcomes of aortic clamping strategies, either transthoracic cross-clamp (TTC, n = 165) or endoaortic balloon occlusion (EAO, n = 93) for patients undergoing minimally invasive mitral valve surgery. Endoaortic balloon occlusion was more commonly used for redo surgery (2% of TTC cases versus 12% of EAO cases). Cerebral stroke was more prevalent in EAO cases than TTC cases (0% versus 4.3%, p = 0.03), although after multivariate adjustment this difference was not significant. There was no difference in aortic dissection rates. The authors determined EAO to be a safe method of cross-clamping, and it is their preferred method for redo procedures.