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Journal and News Scan
Cerfolio and colleagues applied lean and value stream mapping to operating room teams at their academic health center, creating a pilot approach to achieve more efficient operating room turnover. Importantly, a multidisciplinary group of stakeholders who contribute to operating room turnover—from surgeons and anesthesiologists, to nurses, elevator operators, housekeeping staff, infectious disease specialists, and hospital administrators—contributed to reviewing and streamlining the process. By eliminating nonvalued steps and performing other steps synchronously rather than sequentially, among other changes, median operating room turnover time was reduced from 37 minutes (range, 26 - 167 minutes) to 14 minutes (range, 10 - 45 minutes).
Although both bicuspid aortic valve (BAV) and Marfan syndrome have been associated with aortic dissection risk, it is unknown if the presence of BAV is associated with an increased aortic risk in patients with an FBN1 gene mutation. Milleron and associates evaluated aortic diameters, aortic valve function, aortic shape and aortic events during follow-up in 1437 patients with an FBN1 gene mutation, 26 of whom (1.8%) had a BAV.
Patients with BAV had a larger aortic root maximal diameter and normalized Z score at all ages compared with patients with tricuspid aortic valve. Patients with BAV were more likely to have prophylactic aortic root surgery at a younger age, although the aortic diameter threshold was similar in the two groups. No aortic dissection was seen in patients with BAV.
In patients with a FBN1 mutation, BAV is associated with larger aortic root diameter, with no difference in evolution of Z score with age. A trend was found towards prophylactic aortic root surgery at younger ages but similar aortic diameter thresholds without occurrence of aortic dissection. This study found no evidence for lowering aortic diameter thresholds for prophylactic root surgery in the presence of BAV in patients with FBN1 mutations.
Engelhardt and colleagues describe a high-fidelity training simulator for minimally invasive mitral valve surgery. The novelty of this simulator was the fact that it was equipped with new silicone replicas of patient-specific pathological mitral valves. Five expert surgeons and seven residents performed mitral valve surgery using the simulator, with the skills of all the trainees being improved in just one simulation session.
Boersma and associates reported the outcomes of left atrial appendage (LAA) closure with the Watchman device in international registry (EWOLUTION), which recruited 1,020 patients from 47 different centers. Mean age was 73.4 years and 49% had a CHA2DS2-VASc score of 5 or higher—indicating a high risk of stroke.
After a median follow-up of two years, the following outcomes were observed:
- Twenty-two strokes, or 1.3 per every 100 patient-years, which correlates to an 83% reduction in strokes compared to historic data of the population’s risk profile.
- Forty-seven nonprocedural bleeding events, translating to 2.7 per 100 patient-years—a 46% reduction versus historic data.
- Stroke and bleeding rates were 76% and 41% lower, respectively, compared to historic data among the 311 study participants with prior ischemic stroke. For the 153 participants with prior hemorrhagic stroke, stroke and bleeding rates were 81% and 67% lower, respectively.
- Device thrombus occurred in 34 patients (4.1%).
The authors conclude that LAA closure with the Watchman device was associated with low rates of stroke and bleeding events in high-risk atrial fibrillation patients over a two-year follow-up period.
This review provides a comprehensive overview of the available data on antithrombotic therapy after transcatheter aortic valve replacement.
Antiplatelet therapy (APT) is favored over the use of a vitamin K antagonist (VKA) due to the lower risk of major bleeding associated with APT. Single APT is preferred over dual APT, but dual APT may be required for patients who had an acute coronary syndrome in the previous 6 months, who have complex coronary stenting, who have large aortic arch atheromas, or who had suffered a previous noncardioembolic stroke. VKA monotherapy may be needed for patients with atrial fibrillation or other indications for long-term oral anticoagulation.
Antithrombotic therapy should be selected according to the early device-related risks and the patient’s underlying thrombotic risk. APT should be selected as the primary treatment over VKA unless other indications for VKA are present.
Patient Care and General Interest
In this brief video, an oncologist shares some thoughts on the value of tumor board discussions and the importance of having them early in a patient’s care.
Drugs and Devices
The US Food and Drug Administration has given Investigational Device Exemption approval to the RejuvenAir System from CSA Medical, a bronchoscopic system that uses liquid nitrogen for targeted treatment in chronic obstructive pulmonary disease with chronic bronchitis.
Research, Trials, and Funding
Research presented at the recent Annual Meeting of the International Society for Heart and Lung Transplantation reports on the success of an approach to organ recovery and evaluation for transplant that is based on military-style Special Ops teams.
An association between coffee intake and lung cancer risk, as reported by researchers at the recent Annual Meeting of the American Association for Cancer Research, is noted as interesting but not a finding that should distract from the contribution of smoking to lung cancer.
Biomedical engineering researchers from the University of Arkansas in the USA applied vector flow imaging to improve ultrasound assessment of the heart in two children, demonstrating the feasibility of the technology.
Mick Jagger has undergone a TAVR procedure in New York and is now recovering.
Colorado becomes the second state (after Rhode Island) to require hospitals and ambulatory surgical centers to implement a surgical smoke evacuation system that prevents human exposure to surgical smoke. Effective May 1, 2021, all planned procedures in Colorado which are likely to generate surgical smoke must be conducted in facilities with policies and equipment in place to prevent human exposure to the smoke. According to the estimates of AORN, each year 500,000 healthcare workers, including surgeons, nurses, anesthesiologists, and other staff in the operating room, are exposed to laser or electrosurgical smoke, which can lead to serious and life-threatening respiratory diseases.
In this review, biomedical informatics experts explain what machine learning is with illustrative examples, and they discuss how machine learning can help the work of clinicians including diagnosis, treatment, prognosis, optimizing clinician workflow, and expanding the availability of clinical expertise. The major challenges and vulnerabilities of machine learning are also expounded.
Gu and colleagues developed a surgeon-specific quality monitoring system using a structured database of information derived from electronic health records. Additionally, they used a mobile-based system to provide feedback to surgeons on risk-adjusted mortality, risk-adjusted complications, and other quality measures. The authors report on both the development of the system and the quality measures of top, middle, and bottom performing surgeons, with differences observed only for the rate of internal mammary artery use, the risk-adjusted postoperative length of stay, and risk-adjusted hospitalization cost. They conclude that the system allowed surgeons to compare their own surgical quality with that of their colleagues and identify priorities for improvement.