This site is not optimized for Internet Explorer 8 (or older).
Please upgrade to a newer version of Internet Explorer or use an alternate browser such as Chrome or Firefox.
Journal and News Scan
The International Aortic Arch Surgery Study Group assessed the safety of total arch replacement (TAR) with frozen elephant trunk (FET) for acute type A aortic dissection (ATAAD) with respect to the risks of operative mortality, stroke, and paraplegia.
Data from 978 patients who underwent total aortic arch replacement for ATAAD with or without FET placement were analyzed. In propensity-score matching, there were no significant differences between TAR plus FET versus isolated TAR in terms of permanent neurological deficits (11.9% versus 10.1%, p = 0.59) and spinal cord injury (4.0% versus 6.3%, p = 0.52). Post-hoc propensity-score stratification showed that FET was associated with a statistically significantly lower mortality risk (OR = 0.47, 95% CI 0.239-0.929, p = 0.03).
These results show that the use of FET for ATAAD does not appear to increase the risk of paraplegia in appropriately selected patients at experienced centers.
The Stanford University cardiac surgery team expounds on current evidence for selection of prostheses in valve replacement. While more liberal usage of biologic prostheses in younger patients may be appropriate for the aortic valve, the support for this practice in the mitral position is not as strong. The enthusiasm for biologic valve implantation in the mitral position for young patients should be tempered. As transcatheter technologies continue to develop, the risk-benefit trade-off between biologic and mechanical valves will evolve. However, until procedural safety and long term durability is proven, reliance on these technologies as a routine salvage procedure may be overly optimistic.
Patient Care and General Interest
Washington state will increase the age at which people can purchase tobacco and vaping products to 21, part of a growing Tobacco 21 law movement in the US that has the goal of reducing tobacco usage among teenagers and young adults.
Airbnb is expanding the reach of its Open Homes for Medical Stays program to help cancer patients afford lodging, if they have to travel long distances for treatment.
A report on US physician compensation from Medscape looks at salary and specialty satisfaction, pay disparities between and within specialties, and amount of time spent on paperwork.
Research, Trials, and Funding
Researchers from Germany report that using a comic-style narrative in the informed consent process for coronary angiography improved patient comprehension and reduced patient anxiety.
After finding that white light exposure overnight was harmful for mice recovering from experimental cardiac arrest, researchers want to know if orange-tinted glasses might help mitigate circadian disruption from hospital lights for heart patients.
Researchers from Australia report on their success with hearts transplanted after circulatory death.
Currently no frozen elephant trunk (FET) prosthesis are readily available in the United States. This University of Colorado team developed a surgical technique to simplify the FET procedure, termed the Buffalo Trunk, which obviates the need for a hybrid graft and decreases operating times.
This technique utilizes a soft-branched graft along with a stent graft to create a distal anastomosis that incorporates the aorta, stent graft, and soft graft in a zone 2 arch reconstruction. The preliminary results in 37 patients undergoing the Buffalo Trunk versus 28 undergoing FET showed that the Buffalo technique has facilitated shorter circulatory arrest time, and subsequently overall decreased operative times without compromising outcomes.
The debate over the utility of postoperative incentive spirometry continues. In this instance, the use of a high-tech incentive spirometer that included audible reminders and use tracking was associated with clinical benefit.
The culture of health care creates important challenges for health care professionals. In particular, this culture is 1) hierarchical, 2) competitive, and 3) perfectionistic. Unfortunately, the tendency of acquiescing to those demands is contrary to promoting resonant teamwork. It is important for leaders of multidisciplinary teams to understand how to create environments that flatten the hierarchy (by encouraging all team members to contribute and to genuinely seek the wisdom and knowledge of their colleagues), that encourage collaboration and cooperation (emphasizing collective “wins” and “losses” both for the immediate team as well as for all of us, as a profession), and that invites excellence (which is a process) rather than an expectation of perfection (which is an unrealistic outcome).
In this article, the authors outline the concepts that promote development of this kind of leadership thinking, which covers topics like emotional intelligence, professionalism, interpersonal and communication skills, and efficient, timely, equitable, unprejudiced and patient-centered care.
This a must-read for cardiothoracic surgeons, who are always leading their surgical team.
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.