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Journal and News Scan
Chen and colleagues retrospectively compared outcomes for children who underwent intraoperative device closure of a perimembranous ventricular septal defect (VSD) via two different approaches. VSD closure was performed through a minimal incision in the lower sternum in 52 patients and through a right transthoracic minimal incision in 46 patients. Patients were included if they had small to moderate sized VSDs with at least a 2 mm subaortic rim, mild pulmonary hypertension, and were over one year old, among other criteria. Postoperative complications were comparable between the groups, except for higher incidences of poor surgical wound healing and thoracic deformity in the patients with a lower sternal incision. Short-term follow-up revealed similar outcomes in both groups, and the authors conclude that the right thoracic ventricle approach is an acceptably safe alternative to a lower midline sternotomy for device closure of a perimembranous VSD in children.
Takayuki and colleagues reviewed the outcome of mitral valve replacement after failed mitral valve repair with MitraClip in 25 patients. Perioperative mortality was 28%, and overall one-year survival was 53%. Risk factors for perioperative mortality included preoperative cardiogenic shock, septic shock, and liver failure. Mitral valve regurgitation after MitraClip implantation was usually caused by valve leaflet damage, degeneration, or infection.
An important review in a mainstream periodical read by cardiologist colleagues.
The complete pathologic response rate in this study is revealed to be low, lower than expected after stereotactic ablative radiotherapy (SABR) for early stage non-small cell lung cancer: only 60%. The authors suggest a combined approach (SABR plus surgery), adopted in this experimental phase 2 trial, as a possible management scheme. This is questionable and further research will be needed.
Patient Care and General Interest
One of the professional golfers who qualified for this weekend’s PGA Tour event is also a two-time heart transplant recipient.
Drugs and Devices
Research, Trials, and Funding
A program designed specifically to address racial disparity in lung cancer treatment rates in North Carolina, USA, eliminated this disparity and increased treatment rates for all participants.
Researchers from Ontario, Canada, report a 60% pathologic complete response rate for stereotactic ablative radiotherapy in patients with resectable lung cancer, much lower than they had hypothesized.
A study using data from the UK Biobank found that adults with mild congenital heart defects had increased incidences of heart failure, atrial fibrillation, stroke, and heart attack, even after accounting for cardiovascular risk factors.
The Thoracic Surgery Foundation (TSF) has awarded 24 grants that will support research and educational endeavors in 2019. Visit their website to learn more about TSF and future funding opportunities.
Women have worse outcomes after aortic surgery than men do, report researchers from Ontario, Canada.
Though medical care has become ever more dependent on teamwork, the profession has devoted relatively little attention to what makes for a good team. In this roundtable discussion moderated by Lisa Rosenbaum, panelists Amy Edmondson, Neel Shah, and Thoralf Sundt discuss empirical and cultural approaches to the pursuit of better collaboration.
This audio roundtable is the companion to a three-part series on teamwork, written by Lisa Rosenbaum and published in the New England Journal of Medicine. In this series, Dr Rosenbaum made important reflections on and explorations into the professional, psychological, cultural, and social approaches to fostering high-quality communication and collaboration in the medical community. These articles and links are as follows:
Teamwork — Part 1: Divided We Fall
Teamwork — Part 2: Cursed by Knowledge — Building a Culture of Psychological Safety
Teamwork — Part 3: The Not-My-Problem Problem
Kofler and colleagues evaluated prospectively-measured psoas muscle area in more than 1,000 patients who underwent transcatheter aortic valve replacement at two centers. Indexed psoas area was independently associated with 30-day and follow-up mortality. The authors suggest adding indexed psoas area to The Society of Thoracic Surgeons (STS) score to improve the STS score prognostic value.
A very useful synopsis of treatment strategies for a vexing lethal condition.
Today, The Society of Thoracic Surgeons published the third annual Pediatric Interagency Registry for Mechanical Circulatory Support (PEDIMACS) report. Between Sep 19, 2012 and Dec 31, 2017, 423 patients (less than 19 years of age) in 30 hospitals were supported with 508 devices. The etiology was cardiomyopathy in 261 patients (62%), myocarditis in 48 (11%), congenital heart disease (CHD) in 86 (20%, with 52 of these having single ventricle physiology), and other in 28 (7%). The two most common support strategies included left ventricular assist device in 342 patients (81%) and biventricular assist device (BiVAD) in 64 (15%).
At 6 months, 80% of patients were alive on a device or bridged to transplantation/recovery. Patient characteristics and survival were different among three groups of patients supported with three types of pumps:
- 197 implantable continuous flow pumps: implant age 13.4 ± 3.8 years, 19% INTERMACS profile 1, 21% intubated at implant, 12% with CHD; 92% alive at 6 months
- 79 paracorporeal continuous flow (PC) pumps: implant age 3.9 ± 5.2 years, 49% INTERMACS profile 1, 86% intubated at implant, 38% with CHD; 66% alive at 6 months
- 121 paracorporeal pulsatile pumps: implant age 3.3 ± 3.9 years, 41% INTERMACS profile 1, 77% intubated at implant, 21% with CHD; 77% alive at 6 months
Risk factors for early death were INTERMACS profile 1 (hazard ratio, HR 12.6), BiVAD (HR 3.6), percutaneous devices (HR 13.5), PC pumps (HR 4.1), small volume center (HR 3.3), low age (HR 1.01 for age squared), and low weight (HR 0.9). Intubation (functional capacity, HR 4.3) and liver dysfunction (bilirubin in mg/dL, HR 1.1) at the time of implant were constant hazards.
The investigators conclude that implantable continuous flow pumps are the most common type in children, with greater than 90% survival at 6 months, which may represent the maturation in both patient selection and timing of implantation. Currently paracorporeal continuous flow or pulsatile pumps are limited to supporting most challenging patients, those weighing less than 20 kg, and those with congenital heart defects.
Schubert and colleagues developed a novel trileaflet mechanical heart valve prosthesis. They compared this device with a conventional mechanical bileaflet heart valve in vitro, evaluating hemodynamic parameters and thrombogenicity. The trileaflet valve had a larger effective orifice area and smaller pressure gradient than the bileaflet one. There were fewer clotting deposits on the trileaflet valve, and the authors pointed to the off-wall systolic position of the hinges in the new valve as a major advantage.