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Journal and News Scan
This is a new “real-world” study comparing bleeding risk in Medicare patients treated with dabigatran (n=1302) and warfarin (n=8102) for newly diagnosed atrial fibrillation. The use of dabigatran was associated with a significantly higher risk of any, major, and gastrointestinal bleeding when compared with warfarin. On the contrary, intracraneal bleeding was significantly less common among patients on dabigatran.
The authors performed a single center review to assess outcomes of thoracentesis for inpatients. For 9,320 thoracenteses in 4,618 patients the incidence of adverse outcomes was quite low: pneumothorax 0.6%, reexpansion pulmonary edema 0.01%, and bleeding 0.2%. Current guidelines may not be aligned with outcomes of expert clinical practice.
The authors examined cost-effectiveness in the National Lung Screening Trial (NLST), examining incremental cost-effectiveness ratio (ICER) and quality-adjusted life years (QALYs) associated with low dose CT screening. The ICER was $52,000 per life-year gained and the $81,000 per QALY gained. These values were very sensitive to variations in the screening algorithms.
Long-term QOL outcomes were assessed in a single institution cohort of 63 patients undergoing colon interposition after esophagectomy. 48% of pts had a vagal sparing operation, and resection was performed for cancer in the majority of the pts. Followup median was 13 yrs. Mean SF36 scores were above the published average and GI QOL was 3 out of 4. 84% or more of pts were free of dysphagia, heartburn, and regurgitation. 40% had early satiety. 7 pts required reoperation for redundancy.
The potential benefit of wedge resection vs anatomic resection for stage I and II lung cancer was examined using propensity score matching for pts from the STS Database. Over 3700 pts were matched in each group. Wedge resection was associated with fewer major complications (4.5% vs 9.0%) and lower mortality (1.2% vs 1.9%). Wedge resection reduced pulmonary but not cardiovascular or neurologic complications. The morality reduction for wedge resection was mainly evident in patients with impaired lung function. Cancer outcomes were not assessed, and the relative overall benefit of wedge vs anatomic resection remains to be determined.
Challenges of balancing reduced costs and improved quality were explored for congenital heart surgery linking clinical data from STS Congenital Heart Surgery Database patients to administrative data from the Pediatric Health Information Systems Database. Excess costs associated with any complication were over $56,000, and this increased to more than $132,000 for major complications. The major contributors to excess cost were tracheostomy, pulmonary complications, renal failure, reoperation, and the need for mechanical circulatory support. The Norwood operation offered the greatest opportunity to reduce costs by reducing complications.
The authors explored the impact of wait time for AVR in patients with severe symptomatic aortic stenosis using a single institution database. For patients who were recommended to undergo AVR, wait time mortality at 3 weeks was 1.2% for those scheduled for AVR and 6.9% for those who declined AVR. Wait time mortality for pts undergoing AVR was 3.7% at 3 mos and 11.6% at 6 mos. Prolonged wait time mortality was higher than surgical mortality.
The authors explored readmission rates for heart failure after MV repair/replacement in the US Medicare population as a means for assessing quality. The preop heart failure rate in this population was 61%. Readmission rates were 25% at 30 days and 78% at 5 years; they were substantially higher for those with preop heart failure and were higher for those undergoing valve repair rather than valve replacement.
Left ventricular assist devices (LVADs) are increasingly used for the treatment of end-stage congestive heart failure, both as a bridge to transplantation and as destination therapy (1). The HeartWare HVAD (HeartWare Inc, Framingham, MA, USA) is a continuous centrifugal-flow left ventricular assist device with a magnetic levitating rotor pump. The pump weighs just 140 g and its small design allows for intra-pericardial placement. It is powered by two portable batteries that connect to the pump via a driveline tunneled through the abdominal wall, and these can be worn on a belt, allowing out of hospital support (2). The HVAD is currently indicated for use in patients with refractory end stage congestive heart failure. We outline two techniques for implanting the HeartWare HVAD: via a full median sternotomy, and using minimal access incision
The German Aortic Valve Registry comprises data of 78 centers on conventional, transvascular and transapical valve replacements. After stratification for EuroScore and the German AV score, mortality was comparable with either therapy even for high-risk groups.