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Journal and News Scan

Source: JACC Interventions
Author(s): Bapat V, Frank D, Cocchieri R, Jagielak D, Bonaros N, Aiello M, Lapeze J, Laine M, Chocron S, Muir D, Eichinger W, Thielmann M, Labrousse L, Arne Rein K, Verhoye J, Gerosa G, Baumbach H, Bramlage P, Deutsch C, Thoenes M, Romano M
This multistudy registry, entitled ROUTE, studied the effectiveness and safety of transaortic access for TAVI in 301 patients. Mean age was 82 years and mean STS Score 9.0. Valve success was 97%. Total 30-day mortality was 6.1%, and VARC-2 defined endpoints were reported : stroke (1.0%), MI (1.0%), major vascular complications (3.4%), life-threatening bleeding (3.4) and acute kidney injury (9.5%). Moderate or severe paravalvular leak was present in 3.3% of the cases and 8.8% required a pacemaker.  In the accompanying editorial by Thourani et al. it was highlighted non-transfemoral TAVI accounted for almost 50% of the TAVI cases, but with of the current SAPIEN 3 valves the transfemoral route was used in 90% of the cases. The authors stress that transfemoral TAVI will be the mainstay of TAVI treatment and only the minority of patients are likely to undergo non-transfemoral TAVI.
Source: Journal of the American College of Cardiology
Author(s): Hansson NC, Grove EL, Andersen HR, Leipsic J, Mathiassen ON, Jensen JM, Jensen KT, Blanke P, Leetmaa T, Tang M, Krusell LR, Klaaborg KE, Christiansen EH, Terp K, Terkelsen CJ, Poulsen SH, Webb J, Bøtker HE, Nørgaard BL.
In this retrospective review of 460 consecutive patients undergoing transcatheter aortic valve implantation with the Edwards Sapiens XT or Sapiens 3 prosthesis, the authors analyse the incidence, clinical implications and predisposing factors related to trancatheter heart valve (THV) thrombosis. Of the 460 patients, 405 (88%) underwent multidetector computed tomography in addition to TTE and transesophageal echocardiography (TEE). The incidence of THV thrombosis was 7% (28 of 405 patients). Of these, 5 patients (18%) developed heart failure symptoms during the 12-month follow-up period. The use of a 29 mm THV and no warfarin post-TAVR treatment were independently associated with an increased risk of THV thrombosis. Treatment with warfarin effectively reversed THV thrombosis findings and normalized THV function.
Source: European Heart Journal
Author(s): Eisen A, Cannon CP, Blazing MA, Bohula EA, Park JG, Murphy SA, White JA, Giugliano RP, Braunwald E; IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) Investigators
The authors of this study aimed to examine the safety and efficacy of adding ezetimibe to statin in patients with prior CABG following hospitalization for an acute coronary syndrome (ACS).  In total 1684 post CABG patients were studied. The primary endpoint of cardiovascular death, major coronary events and stroke at a median follow-up of six years occured more often in the simvastatine+placebo group as compared to the simvastatine+ezetimibe group (51.2% versus 60.0%; p for interaction=0.02). This study suggests that adding ezetimibe to simvastatine after ACS in post-CABG patients lowers the risk of cardiovascular events, supporting the use of intensive lipid lowering therapy in these patients.
Source: Journal of Thoracic Oncology
Author(s): Mohsen Ibrahim, Cecilia Menna, Claudio Andreetti, Carlos Puyo, Giulio Maurizi, Antonio D’Andrilli, Anna Maria Ciccone, Domenico Massullo, Camilla Vanni, Giammauro Berardi, Rossella Baldini, Erino Angelo Rendina
The authors investigated an intercostal nerve protection technique compared to standard surgical management of the intercostal space during thoracotomy in a randomized trial.  The nerve protection technique resulted in significantly less pain at 1 day, 1 month and 6 months.  At 1 month and 6 months both spirometry and 6 min walk distance were significantly better in the nerve protection group.
Source: Annals of Thoracic Surgery
Author(s): Paul J Speicher, Zachary W Fitch, Brian C Gulack, Chi-Fu J Yang, Betty C Tong, David H Harpole, Thomas A D'Amico, Mark F Berry, and Matthew G Hartwig
The authors tested the hypothesis that induction therapy improves survival in patients undergoing resection for clinical N1 disease using information from the National Cancer Data Base.  10% of over 5,000 pts were treated with induction therapy.  They were 2:1 propensity matched with patients undergoing the traditional surgery first strategy.  Among surgery first patients, 16% were overstaged (pN0) and 11% were understaged (pN2-3).   There was no difference in short-term outcomes or survival between the two treatment groups.
Source: Annals of Thoracic Surgery
Author(s): The International Cardiac Collaborative on Neurodevelopment (ICCON) Investigators
Operative and postoperative factors' relationship to intermediate term neurodevelopment were assessed in patients who underwent cardiac surgery on bypass at age 9 mos or less using the Psychomotor Development Index (PMI) and the Mental Development Index (MDI).  Lower PDI and MDI were associated with longer interoperative support time, with use of ECMO or VAD, and with longer postoperative length of stay.  After adjusting for patient, preoperative, operative, and postoperative factors, the operative and postoperative factors accounted for only 5% of the variance, suggesting that preoperative and patient factors have the most impact on postoperative neurodevelopment.
Source: Annals of Thoracic Surgery
Author(s): Alison M. Pouch, Benjamin M. Jackson, Eric Lai, Manabu Takebe, Sijie Tian, Albert T. Cheung, Y. Joseph Woo, Prakash A. Patel, Hongzhi Wang, Paul A. Yushkevich, Robert C. Gorman, Joseph H. Gorman
The authors evaluated the accuracy of a semi-automated method of developing 3D images of mitral valve disease, generated from 3D echocardiograms, in clinical decision making.  Resulting images were very similar to images created through laborious analysis by hand of echo results, and were dissimilar to images of normal mitral valves.  The clinical utility of this technology will need to be assessed.
Source: Annals of Thoracic Surgery
Author(s): John P Nabagiez, Masood A Shariff, William J Molloy, Seleshi Demissie, Joseph T McGinn Jr.
The utility of a home visit program for patients discharged to home after cardiac surgery was assessed comparing a 4 year cohort of home visit patients to patients operated prior to the home visit program initiation.  Home visits decreased readmission rates by about 40%.  Costs per readmission were $40,000 to $56,000, whereas the cost of the entire program for 363 pts was only $25,000. This translated to a 2-year savings of nearly $1 million, and $39 in savings for each $1 invested.
Source: Annals of Thoracic Surgery
Author(s): Matthew L. Williams, MD, Joseph E. Bavaria, MD, Michael A. Acker, MD, Nimesh D. Desai, MD, Prashanth Vallabhajosyula, MD, W. Clark Hargrove, MD, Pavan Atluri, MD, Wilson Y. Szeto, MD
This single-center retrospective study evaluated outcomes of ESRD patients undergoing valve surgery based on whether they received either a mechanical or tissue valve.  The study spanned the years 2002-2014, and included 64 mechanical and 151 tissue valve replacements.  Even after controlling for confounding variables--given the short expected survival in these patients--there is no salutary effect of using a mechanical over a tissue valve.   Comment:  Given the morbidity of anticoagulation in, and the shorter lifespan of, ESRD patients, should we be using mechanical valves at all in these patients?
Source: Annals of Thoracic Surgery
Author(s): John P. Nabagiez, MD, Masood A. Shariff, MD, William J. Molloy, PA-C, MPH, Seleshi Demissie, DrPH, Joseph T. McGinn Jr., MD
This retrospective study analyzed the relative cost-effectiveness of a physician assistant home care (PAHC) program in terms of readmission rates, length of stay, and health care cost.  The study hospital switched from a conventional discharge treatment plan (control) in September 2010 to a PAHC program.  A total of 1,185 patients who were discharged home after cardiovascular surgery were included in the analysis. The authors found the following: Readmission rates decreased by 41% for propensity-matched patients. There was no signifiant difference in LOS. Institution of the PAHC program saved $39 for every incremental dollar spent on the program.   Comment:  Accordingly, this single center study suggests that the institution of a PA (or NP) home visit program may be extremely cost-effective.  This is a strategy that may make a great deal of sense of bundling of payments for cardiovascular services becomes mainstream.  

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