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Journal and News Scan
The outcomes of failed mitral clipping were evaluated in 19 pts. Surgical risk score increased significantly between the time of clipping and subsequent remedial surgery. Severe valve tissue damage as a result of clip application was evident in most patients. Valve repair was possible in 83% of pts who had a single clip, whereas only 23% of patients with more than one clip could have valve repair. One year survival was 68%.
A multivariable analysis was performed on data from 4 European centers for outcomes comparing trans-apical (TA; 10%) and transfemoral (TF; 90%) AVI. TA-AVI pts had higher predicted risk and more comorbidities. TA-AVI was associated with increased complications, hospital stay, 30 day mortality, and all cause long-term mortality.
Genetic variation in interleukin-17 receptor A is functionally associated with chronic rejection after lung transplantation
The aim of this genetic study conducted on a large lung transplant population is to demonstrate the relationship between some genetic variants of IL-17 and IL-23 and the risk of development of chronic allograft rejection. This association could lead to new ways of prevention and treatment.
Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation: Impact on Late Clinical Outcomes and Left Ventricular Function
This is a multicentre retrospective study of 1556 patients undergoing transcatheter aortic valve implantation (TAVI) with self expandable valves (SEV) and balloon expandable valves (BEV), evaluating the effect of permanent pacemaker implantation (PPI) on outcomes at two years. 15.4% of the patients required PPI. Not surprisingly, the need for PPI was significantly higher in patients receiving a SEV (25,5%) than in patients receiving a BEV (7,1%). There was no difference in the primary outcome of the study, which was defined as a composite of all-cause mortality and hospitalization due to heart failure at last follow-up. Interestingly, there was a lower rate of unexpected death in patients with PPI. Left ventricular ejection fraction improved in patients with no PPI but worsened in those patients with PPI.
The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection
This retrospective analysis compares outcomes in patients with aortic intramural hematoma type B (IMHB) to those with type B aortic dissection (ABAD) in patients enrolled in the International Registry of Acute Aortic Dissection (IRAD). There was no difference in in-hospital mortality between the two groups. Patients with IMHB required surgical intervention less frequently than ABAD, with the indications for intervention being the same for the two groups (rupture, malperfusion, refractory pain or hypertension). Periaortic hematoma was observed more often in patients with IMHB and was identified as a risk factor for rupture. Patients with ABAD had significantly more dilation of the descending aorta during follow up and more often had extension into the abdominal aorta than those with IMHB. The authors concluded that IMHB may have a more indolent clinical course than ABAD.
Preoperative Risk Factors of Bleeding and Stroke during LVAD Support: An Analysis of Over 900 HeartMate II Outpatients
This article by Boyle et al. investigates risk factors that are associated with higher rates of bleeding, stroke and pump thrombosis after LVAD implantation. The authors analyzed 956 patients who underwent Heartmate II implantation as a bridge to transplant (n=405) or as a destination therapy (n=551). They found that gender, age, etiology of heart failure and body mass index were significantly associated with higher risk of bleeding and thrombotic events in LVAD patients.
Arterial grafts balance survival between incomplete and complete revascularization: A series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts
In this article by Kieser and colleagues in which they analyzed 1000 patients receiving CABG, the authors report that when using arterial grafts, incomplete revascularization (occurrence, 14%) was not associated with increased midterm mortality over a median of 54 months in patients <80 years of age (HR 1.2, 95% CI 0.7-2.1), while it was in patients >80 years old (HR 5.7, 95% CI 1.8-18.0).
This study by Dimitrova et al included 1339 patients who underwent CABG of which 332 patients received a LIMA with a radial artery and 1007 a LIMA with a SVG. In a propensity-matched cohort of 283 pairs, Kaplan-Meier survival in the radial artery versus SVG group at one year (99% vs. 97%), 5 years (93% vs. 87%), 10 years (80% vs. 72%) and 15 years (70% vs. 58%) favoured those receiving a radial artery (P=0.018). In a propensity-score adjusted multivariate analysis of the entire cohort, the use of a radial artery remained an independent predictor of long-term mortality: hazard ratio 0.64, 95% CI 0.44-0.90; P=0.017).
Impact of Preoperative Mod/Sev MR on 2-Year Outcome After TAVI and AVR Insight From the PARTNER Trial
In this paper the authors use data from cohort A of the PARTNER trial to evaluate the effect of preoperative moderate to severe mitral regurgitation on survival at two years in patients treated with surgical aortic valve replacement (SAVR) and TAVI. Mitral regurgitation improved significantly in both groups at 30 days. Preoperative mitral regurgitation had a negative effect on survival in the SAVR group but not in the TAVI group. The authors conclude that TAVI may be a reasonable treatment option in a selected group of patients with aortic stenosis and mitral regurgitation.
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment to aortic valve replacement (AVR) for selected patients with severe aortic stenosis. The present systematic review was conducted to analyze the cost–effectiveness of this novel technique within reimbursed healthcare systems. Depending on the ICER threshold selected, TAVI is potentially justified on both medical and economic grounds compared with medical therapy for patients deemed to be surgically inoperable. However, in the high–risk surgical patient cohort, the evidence is currently insufficient to economically justify the use of TAVI in preference to AVR.
- Two reviewers used 7 electronic databases from January 2000 to November 2012 to identify relevant cost-effectiveness studies of TAVI versus AVR or medical therapy.
- The primary endpoints were the incremental cost-effectiveness ratio (ICER) and the probability of cost-effectiveness.
- The eligible studies for the present systematic review included those in which the cost-effectiveness data were measured or projected for TAVI and either medical therapy or AVR.
- All forms of TAVI were included, and all retrieved publications were limited to the English language.
- Eight studies were included for quantitative assessment.
- The ICER for TAVI compared with medical therapy for surgically inoperable patients ranged from US$26,302 to US$61,889 per quality-adjusted life year gained.
- The probability of TAVI being cost-effective compared with medical therapy ranged from 0.03 to 1.00.
- The ICER values for TAVI compared with AVR for high-risk surgical candidates ranged from US$32,000 to US$975,697 per quality-adjusted life year gained.
- The probability of TAVI being cost-effective in this cohort ranged from 0.116 to 0.709.