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Journal and News Scan
This article concludes that five-year survival and morbidity rates in patients over 75 years of age did not differ between off-pump and on-pump groups. The main determinant of poorer long term outcome was incomplete revascularization.
Patient Care and General Interest
Drugs and Devices
Fresenius Medical Care will begin distributing CytoSorbents Coporation’s CytoSorb® blood purification technology in Korea and Mexico, with the aim of serving critically ill and cardiac surgery patients in both countries, pending market registration clearance from the respective local health authorities.
CorMatrix Cardiovascular, Inc, received investigational device exemption from the US Food and Drug Administration for the early feasibility study of their Cor ECM® Tricuspid Valve.
Research, Trials, and Funding
The negative effects of unconscious bias and approaches to work against it were in focus at the recent Annual Meeting of The Society of Thoracic Surgeons in San Diego, California.
Also at January’s STS Annual Meeting, a team from Oregon Health and Science University in Portland presented their experience with intraoperative autologous blood donation in cardiac surgery and a group from Pennsylvania Hospital in Philadelphia presented their efforts to promote on-table extubation after coronary artery bypass.
Researchers from Hokkaido University in Japan have engineered an adenovirus that selectively replicates in cancer cell lines including lung cancer, which they used to suppress tumor cell growth in mice.
In this art of operative techniques segment, Colli and colleagues provide an illustrated description on how to perform transapical NeoChord implantation. The authors’ detailed description includes patient positioning, accurate exposure and important landmarks, and guidance on how to safely maneuver intracardiac instruments under transesophageal echocardiographic guidance.
The European Journal of Vascular and Endovascular Surgery published The European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aortoiliac artery aneurysms. This is an important reference for cardiothoracic and vascular surgeons who are engaged in the care of patients with aortic disease.
The document covers several topics that were not addressed in the 2011 guidelines, including: 1) juxtarenal abdominal aortic aneurysm (AAA), isolated iliac aneurysms, mycotic and inflammatory aneurysms, and concomitant malignant disease; 2) new treatment concepts, such as fenestrated endovascular aneurysm repair (EVAR), chimney EVAR, and endovascular aneurysm sealing; 3) service standards and logistics of importance, including surgical volume requirements and acceptable waiting time for surgery; and 4) the patient's perspective - a topic that is included for the first time in an ESVS guideline.
Several updated recommendations have been made based on new data or evidence for already established topics, including: 1) recommendations on an EVAR-first strategy for ruptured AAA; 2) a stratified, less frequent follow-up regimen after EVAR; and 3) an updated surveillance protocol for small AAAs and subaneurysms.
In the February issue of The Annals, The Society of Thoracic Surgeons published the first annual report after the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) joined the STS National Database in January 2018. This report summarizes the outcomes in patients (≥19 years of age) undergoing durable MCS implant between June 23, 2006, and December 31, 2017.
Among 25,145 patients, 18,539 (74%) received continuous flow left ventricular assist devices (CF LVADs), 667 (2.6%) had a right ventricular assist device (RVAD) with CF LVAD, 339 (1.3%) received a total artificial heart, and 20 (0.07%) received an isolated RVAD. Of the CF LVADs, mean age was 57 ± 1 years, 26% were listed for transplantation, and 51% were in cardiogenic shock (profile 1 to 2) preoperatively. CF LVADs included 14,527 axial flow (78%) and 4,012 centrifugal flow (22%) devices. Recently (2012-2016), more patients are in Intermacs profile 3, with better renal and hepatic function, and received implants for destination therapy (48%), with a centrifugal flow device (51%).
Mean CF LVAD support duration was 20 months. Survival for isolated CF LVADs was 83% at 1 year and 46% at 5 years. One-year survivals for centrifugal versus axial flow devices were 85% and 84%, respectively. Patients with concomitant RVAD support had 1-year and 5-year survivals of 58% and 28%, respectively. Freedom from all-cause readmission was 70% at 1 month and 20% at 1 year. At 1 year, stroke occurred in 20% with centrifugal flow and 13% with axial flow support (p < 0.001), gastrointestinal bleeding affected 20% with centrifugal flow devices and 25% with axial flow devices (p < 0.001), and pump-related infection occurred in 28% of patients with centrifugal flow devices versus 25% with axial flow devices (p = 0.01). Neurologic dysfunction (19% of deaths) and multisystem organ dysfunction (15%) were the most common causes of death.
Park and colleagues evaluated the effect of neoadjuvant chemotherapy for thymic cancers, comparing postoperative outcomes and long-term survival between 102 matched pairs of patients who underwent either upfront resection or resection after neoadjuvant chemotherapy. Postoperative complications and hospital length of stay were similar between the groups, as were three-year recurrence-free survival and five-year overall survival.
On February 4, 2019, Cook Medical announced recent approval from the US Food and Drug Administration for its Zenith Dissection Endovascular System. The system consists of a proximal stent-graft component and a distal bare stent component. It provides a less invasive alternative to open surgery for repair of type B dissections. The device will be available for sale in the United States in the coming months.
In this prospective single-institution study, functional status trajectory one year after intervention was compared for transcatheter (TAVR) versus surgical aortic valve replacement (SAVR). A moderate/large decline compared to preintervention status occurred in 23% of TAVR patients and 4% of SAVR patients. A frailty index, postoperative delirium, and procedure-related complications were associated with postintervention decline.
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.