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Journal and News Scan
March 21, 2019
Submitted by: Wei-Guo Ma
Researchers of the Canadian Thoracic Aortic Collaborative (CTAC) analyzed the operative outcomes in 1653 patients (30% women) undergoing thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite (STS-COMP) for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation).
Compared with men, women were older (66 versus 61 years; P < 0.001) and had more hypertension and renal failure, but they had less coronary disease, less previous cardiac surgery, and higher ejection fractions. Rates of aortic dissection were similar between two genders, as were rates of hemiarch, total arch, and thoracoabdominal aortic repair. However, women had less aortic root reconstruction, including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P < 0.001). Men had longer cross-clamp and cardiopulmonary bypass times than women, but they had similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women had a higher rate of death (11% versus 7.4%; P = 0.02), stroke (8.8% versus 5.5%; P = 0.01), and STS-COMP (31% versus 27%; P = 0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio [OR], 1.81; P < 0.001), stroke (OR, 1.90; P < 0.001), and STS-COMP (OR, 1.40; P < 0.001).
Given the worse outcomes in women, the authors call for earlier surgery once diagnosis of thoracic aortic disease is made in women and further investigation to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.
March 20, 2019
Submitted by: Claire Vernon
Yanagawa and colleagues evaluated the experience of 10 centers in Ontario, Canada, participating in the Ontario Transfusion Coordinator (ONTraC) program to determine if red blood cell transfusion rates were reduced by patient participation in the program and optimization of hemoglobin prior to coronary artery bypass grafting (CABG). The authors discuss the ONTraC program, noting that the first 60 consecutive patients undergoing CABG at each center each year were referred for assessment. After this, patients were referred only upon physician request. Over the 10 years following the start of the program, overall transfusion rates fell from 40.1% to 26.2%. Patients who were assessed by an ONTraC coordinator were more likely to be older, to be women, and to be anemic, but despite this, no differences were found in overall transfusion rates between patients who were and were not assessed. When patients were stratified by World Health Organization Anemia Classification, patients with both mild and moderate-to-severe anemia who were assessed prior to CABG had lower transfusion rates than patients with anemia who were not assessed.
March 20, 2019
Submitted by: Wei-Guo Ma
Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available.
In this study, the vascular team from NYU Langone Hospital in Brooklyn, New York, retrospectively analyzed their experience in 18 patients who underwent D-TEVAR between March 2014 and January 2018. No major complications occurred. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support.
Although these data suggest that cardiothoracic surgery support is not required D-TEVAR, the conclusion should be interpreted very cautiously. The importance of multidisciplinary collaboration in treating patients with aortic disease cannot be overemphasized.
March 19, 2019
Submitted by: Wei-Guo Ma
This review summarizes recent promising applications of artificial intelligence (AI) in cardiology and cardiac imaging, which potentially add value to patient care.
Problems with timing, efficiency, and missed diagnoses occur at all stages of the imaging chain. The application of AI may reduce cost and improve value at all stages of image acquisition, interpretation, and decision-making. The main fields of AI for imaging will pertain to disease phenotyping, diagnostic support, and image interpretation. Grouping of relevant clinical and imaging information with cluster analysis may provide opportunities to better characterize disease. Diagnostic support will be provided by automated image segmentation and automated measurements. The initial steps are being taken towards automated image acquisition and analysis. “Big data” from imaging will interface with high volumes of data from the electronic health record and pathology to provide new insights and opportunities to personalize therapy.
March 18, 2019
Submitted by: Aristotle Protopapas
A number of interesting findings in early follow up of this randomized controlled trial on one type of transcatheter aortic valve against conventional surgery: the mechanics of the valve and the incidence of complete heart block, to name but a few. We await the longer follow up.
March 17, 2019
Submitted by: Wei-Guo Ma
The American College of Cardiology's 68th Annual Scientific Session has released the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. This guideline includes newly generated recommendations for control of blood presssure, cholesterol and type II diabetes, aspirin use, regular exercise and physical activity, heathier diet, and tobacco use, in addition to recommendations related to team-based care, shared decision-making, and assessment of social determinants of health, to create a comprehensive yet targeted ACC/AHA guideline on the prevention of atherosclertoic cardiovascular disease.
March 16, 2019
Submitted by: Mark Ferguson
The institution-specific uptake of VATS for lung cancer resection in the US Veterans Affairs system was evaluated over the past 15 years. Uptake more than tripled during the study period, with a current mean of more than 50% among institutions. However, uptake ranged from 0 to 82% and was associated with increasing center volume.
March 15, 2019
Submitted by: Claire Vernon
Drugs and Devices
The US Food and Drug Administration (FDA) announced that the indications for the MitraClip™, made by Abbott, have been expanded to include secondary mitral regurgitation.
Saranas, Inc, announced that it’s Early Bird Bleed Monitoring System for detecting bleeding events during endovascular procedures was granted de novo classification by the US FDA.
European regulators offered decisions on immunotherapies for treating advanced lung cancer, with Roche’s atezolizumab and Merck’s pembrolizumab receiving approvals for expanded indications from the European Commission, and Pfizer’s lorlatinib being endorsed by the European Medicines Agency’s drug review panel.
Research, Trials, and Funding
An educational initiative that provided cardiac surgeons with information on their transfusion rates reduced blood utilization without affecting quality measures, a finding that was presented at the recent American College of Cardiology’s Cardiovascular Summit in Orlando, Florida.
Researchers in Japan report that the number of operations performed for complex congenital heart disease in Japan increased following the 2011 earthquake and nuclear accident in Fukushima.
Cardiac MRI shows promise for predicting allograft rejection in heart transplant recipients, say researchers from Chicago, Illinois, USA.
March 15, 2019
Submitted by: Wei-Guo Ma
Researchers from the University of British Columbia, Seattle and Belgium successfully used a new approach that significantly minimized brain damage caused by ischemic stroke in mouse models. The new approach works by blocking hemichannels—pathways allowing for the flow of chemical ions and small molecules—that are expressed by astrocytes, ie, cells playing a protective role for neurons in the brain.
The hypothesis is that when stroke occurs, these hemichannels open and leak toxic molecules into the space outside the astrocytes, causing inflammation and damage to neurons; therefore, blockade of these channels may minimize damage to the brain during stroke.
In this study, a genetic approach that mutated the channel proteins, called Connexin-43 (Cx43), was used to block the formation of hemichannels. This allows the astrocytes to protect the neurons, significantly reducing the size of the stroke injury in the brain. Pharmacological blockade of Cx43 hemichannels with a molecule called TAT-Gap19 in the same ischemic stroke model, also resulted in smaller stroke damage.
These two approaches demonstrate that Connexin hemichannel blockers could be used as a neuroprotective agent in stroke. Thus, a new treatment of ischemic stroke may soon be possible.
Connexin hemichannel blockers also have a potential role in treating other neurodegenerative conditions such as traumatic brain injury and Alzheimer's disease.
March 15, 2019
Submitted by: Aristotle Protopapas
Very useful open access review, especially the simple figure on page 959.