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Journal and News Scan
This keynote lecture highlights the need for a standardized prepump intraoperative echocardiology protocol in order to provide a surgeon and their team with a roadmap as to what techniques may be applied for an effective repair of the aortic valve. The authors conclude that such a protocol is essential in enhancing the heart team’s approach by providing a common language between surgeons and echocardiologists, which they hope will ultimately increase aortic valve repairs for select patients in expert centers.
Thoracic stentgrafts are stiffer than the aorta. To understand how this mismatch might affect the left ventricle, van Bakel and colleagues quantified the left ventricular remodeling after thoracic endovascular aortic repair (TEVAR) in 8 patients. They estimated an increase in left ventricular stroke work and found an increase in left ventricular mass after TEVAR. The authors conclude that compliant endografts should be developed to prevent adverse left ventricular remodeling after TEVAR.
Holm and colleagues evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients who were taking P2Y12 inhibitors. Patient outcomes from the European Multicenter Registry on Coronary Artery Bypass Grafting were included in the analysis, with 1,293 patients who received clopidogrel preoperatively and 1,018 who received ticagrelor. The authors observed a higher incidence of major bleeding in patients when these therapies were discontinued for fewer days prior to CABG, and they suggest postponing nonemergent procedures for at least 3 and 4 days after discontinuation of ticagrelor and clopidogrel, respectively.
Rodríguez-Caulo and colleagues report a retrospective multicenter study on almost 1,500 patients aged 50-65 who underwent aortic valve replacement with mechanical or biological prosthesis. The mean length of follow-up was 8 years. There was no significant difference in survival between the valve types. There was a higher rate of major bleeding in patients with mechanical prosthesis; however, reoperation was more frequent among those with a biological prosthesis. The authors conclude that a bioprosthesis in patients of age 55 years and older is a reasonable choice.
Patient Care and General Interest
San Francisco, California, passed an ordinance to ban the sale of e-cigarettes in the city, the first such ordinance in the USA.
The US Centers for Medicare & Medicaid Services (CMS) has released the anticipated update to the national coverage decision for transcatheter aortic valve replacement. The full decision memo is available on the CMS website.
Patient-specific 3D modeling is used to aid planning of a complex chest wall reconstruction.
A brief interview with the chief of cardiothoracic surgery at Phoenix Children’s Hospital in Arizona, USA, focuses on the importance of transparency and a true team attitude to achieve the best possible patient outcomes.
Research, Trials, and Funding
Researchers from Vanderbilt University in Tennessee, USA, report that among adults diagnosed with lung cancer, a smaller proportion of black Americans than white Americans would have qualified for screening.
In this systematic review, Arnaoutakis and colleagues evaluated the repair durability and survival of patients who underwent repair for a bicuspid aortic valve (BAV). Twenty-six studies were evaluated after full exclusion criteria were applied. BAV repair was demonstrated to have low operative mortality and excellent 5-year survival. Variations in surgical technique (eg, in reimplantation or remodeling), were not associated with protection from reintervention. Systematic assessment of cusp height and annular stabilization favored long-term durability, and increased leaflet calcification was noted to have higher rates of reintervention.
Social media offers enormous potential benefits for both care providers and patients, because the platform allows for the dissemination and gathering of information and has the innate ability to network globally. The Cardiothoracic (CT) Ethics Forum functions as the ethics educational arm for the CT surgical community, producing ethics-related programs at major CT surgery meetings and subsequently publishing articles on those proceedings as well as ethical topics in CT surgical and other medical specialty journals. The Forum has constructed a very important and useful set of recommendations for CT surgeons as they engage with social media.
An interesting small British-led randomized controlled trial on modern imaging of coronary atheroma.
This is a cohort study from the Pediatric Cardiac Care Consortium based on data from 616 patients with pulmonary atresia with intact ventricular septum (PA/IVS) treated between 1982 and 2003. Median follow-up was 16.7 years (IQR 12.6-22.7).
Initial interventions included aortopulmonary shunt in 247, right ventricular decompression in 96, and both in 273. Risk factors for death at initial intervention included earlier birth era (1982-1992), chromosomal abnormality, and atresia of one or both coronary ostia. Among 494 survivors of neonatal hospitalization, there were 99 deaths (4 posttransplant) and 10 transplants (median age of death or transplant 0.7 years, IQR, 0.3-1.8). Definite repair or last-stage palliation was achieved in the form of completed 2-ventricle repair (n=201), one-and-a-half ventricle (n=39), or Fontan (n=96). Overall 20-year survival was 66%, but for patients discharged alive after definitive repair, it reached 97.6% for single-ventricle patients, 90.9% for those with one-and-a-half ventricle, and 98.0% for those with complete 2-ventricle repair (log-rank p=0.052).
The authors conclude that transplant-free survival in PA/IVS is poor due to significant infantile and interstage mortality. Survival into early adulthood is excellent for patients reaching completion of their intended treatment path, independent of type of repair.
Colleagues from five heart centers performed a study on the incidence and factors associated with acute stroke following type A repair using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).
Among 7353 Acute type A repair performed at 772 centers between 2014 to 2017, operative mortality was 17% and incidence of postoperative stroke was 13%. Multivariate analysis showed that patients with axillary cannulation versus femoral (OR=0.60, P<0.001) and retrograde cerebral perfusion versus no cerebral perfusion (OR=0.75, P=0.008) or antegrade cerebral perfusion (OR=0.75, P=0.007) were less likely to develop acute stroke, while total arch replacement versus hemi-arch technique (OR=1.30, P=0.013) was predictive of higher risk for stroke. Longer times of circulatory arrest, cerebral perfusion and cardiopulmonary bypass were all related to higher risk of postoperative stroke. The degree of hypothermia and center volume were not related to stroke incidence.