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Journal and News Scan
August 19, 2015
Submitted by: Lisa Brown
This is the authors' reply to the letters submitted to The Lancet Oncology. They begin by stating that the strength of their analysis was that patients were randomised, thereby avoiding selection bias. With regards to low accrual, one major factor was failure of thoracic surgeons to participate. In addition, stage I NSCLC is relatively uncommon. They state that the median follow-up was long enough to discover recurrences and that there were enough patients to accurately analyze the data from a statistical standpoint. For patients in the ROSEL trial who did not undergo biopsy, clinical staging via PET scan has been shown to have a low false positive rate in the Netherlands. When considering VATS versus thoracotomy, cancer outcomes are not improved by VATS, readmission for complications of VATS is similar to thoracotomy, and nodal upstaging for clinical stage I NSCLC is more common after thoracotomy, although extent of lymph node dissection does not affect outcomes. Therefore the possible superiority of VATS may not lead to a clinically significant improvement in the surgical treatment of these patients. With regards to comorbidities, all patients underwent cardiopulmonary testing to determine their surgical candidacy. Zhang and colleagues had disagreed with the use of SABR and EBUS for concern that lymph node involvement would be understaged and those patients would miss out on adjuvant therapy. The original article showed no difference in regional recurrence between the two groups. Opitz and colleagues graded the original article, but Chang and colleagues replied that the randomised design of the two trials translates to a higher level of evidence than prior studies. Chang clarifies that the 30-day surgical mortality was 0%, but the 90-day mortality was 3.7% which is less than recent published literature. The authors respond to Dearman and colleagues' suggestion regarding NHS England and CtE by stating that there is already a considerable amount of data comparing SABR versus surgery. The authors finish by stating that they continue to support their conclusion that SABR is a non-invasive standard treatment alternative to surgery for patients unable to undergo surgery and should also be considered a viable treatment option for patients who are surgical candidates.
August 18, 2015
Submitted by: Philip McElnay
This paper is now one of the largest meta-analyses performed to compare off and on pump CABG. It demonstrates comparable outcomes between the two groups.
August 16, 2015
Submitted by: Ruben Osnabrugge
The authors investigate the safety of minimally invasive Transcatheter Aortic Valve Replacement (MA-TAVR) and its learning curve. MA-TAVR was performed by a team consisting of a cardiologist and cardiac surgeon. The patient was teated in a catheterization laboratory under conscious sedation. During the series the routine changed from transferring patients to the ICU to transferring patients to a regular telemetry room. The authors found in 151 consecutive cases that the majority of patients were high surgical risk (STS-PROM of 10.0%). The rates of major stroke (3.3%), major vascular complications (3%) and paravalvular leak (7%) did not change over time. The authors conclude that in a high-volume TAVR center, MA-TAVR is feasible. Moreover, they conclude that the learning curve for moving from regular TAVR to MA-TAVR is small and that TAVR centers actively pursue the minimalist technique.
August 14, 2015
Submitted by: J. Rafael Sadaba
This is an observational outcome study for the comparative effectiveness of SAVR–TAVR procedures for the treatment of severe aortic stenosis at 93 Italian centers. From the entire cohort of 5468 patients, 650 pairs of patients who underwent SAVR and transfemoral TAVR with similar baseline demographic and clinical characteristics were obtained using a propensity score method.
The primary endpoints of this analysis were death from any cause, and major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Transfemoral TAVR was comparable to surgical replacement with respect to 1-year rates of death from any cause, MACCE, and repeat hospitalization due to cardiac reasons. Nevertheless, in the TAVR group there was a higher incidence of paravalvular leak, major vascular damage and need for pacemaker.
August 14, 2015
Submitted by: Arie Blitz
The Texas Heart Institute reports its experience with 27 patients with prior continuous flow LVADs who had undergone varying degrees of device explantation. Although the numbers are small, the explantation methods ranged from near-complete device removal to driveline transection and removal. In general, the device explantation technique has evolved over time to a progressively less invasive option. This experience provides justification for a tailored approach, but lesser degrees of device removal appear to be well tolerated. The exception may be patients with chronic device infection: 6 of 10 patients with superficial driveline infection required further procedures for either debridement or removal of infected device material. More radical explantation of device material is recommended in these patients.
August 12, 2015
Submitted by: Arie Blitz
A single institution retrospectively reviewed the correlation of preoperative serum albumin level with outcomes after LVAD implantation from 2006 to 2014. A lower albumin level was associated with a significant increase in postop renal failure and prolonged hospitalization, but not overall short-term and long-term survival.
August 11, 2015
Submitted by: Mark Ferguson
This single institution retrospective study evaluated the relationship of adenocarcinoma subtype to long-term survival after resection of stage I lung cancer. Patients with solid-predominant tumors experienced recurrences earlier, more often in distant sites, and more often in multiple locations. This subtype was also independently associated with worse post-recurrence survival.
August 9, 2015
Submitted by: Lisa Brown
Case series of 500 consecutive patients undergoing POEM from September 2008 through November 2013 at a tertiary referral center in Japan. At 2 month follow-up, the success rate was 91.3% (defined as Eckardt score < 2 or reduced > 4 points). Two hundred sixty-eight patients had esophagitis on endoscopy (64.7%), but only 71 (16.8%) had reflux symptoms. At 1-2 years, the success rate was 91%, 9 of 16 patients has esophagitis on endoscopy, and 19.4% had heartburn symptoms. Lastly, at 3 years the success rate was 88.5%, again 9 of 16 patients had esophagitis on endoscopy, and 56.3% had heartburn symptoms. Complications occurred in 16 patients (3.2%), the most severe being 1 pneumothorax requiring a chest tube and 1 case of bleeding controlled endoscopically but requiring blood transfusion; there were no deaths. The authors point out that one advantage of POEM over Heller myotomy is that the length of the myotomy can be better tailored to the individual patient.
August 6, 2015
Submitted by: Arie Blitz
This retrospective analysis of the BTT continuous flow (CF) LVAD experience from Harefield Hospital addresses the question: "What are the predictors of the requirement for an RVAD at the time of LVAD implantation?" Of the 152 patients included in the study, 23% underwent RVAD implantation. Of all the univariate predictors of the requirement of an RVAD, the two significant independent variables on multivariate analysis were the preop TAPSE (tricuspid annular plane systolic excursion) and the left atrial diameter. Of note, a TAPSE value of <12.5 mm had an 84% sensitivity and 75% specificity for predicting the requirement for an RVAD.
August 3, 2015
Submitted by: J. Rafael Sadaba
In this manuscript the authors describe their findings in a retrospective review of prospectively obtained 5-year follow up data on 353 patients undergoing transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis in 8 Italian centres.Transfemoral access was used in 317 patients (89.8%); in the rest of the patients in whom the transfemoral approach was not feasible, a trans-subclavian access was employed. During follow-up, there were 241 re-hospitalizations for cardiovascular reasons in 164 (46%) patients. Acute heart failure was the most frequently reason reported (42.7%), followed by requirement of permanent pacemaker implantation (17.4%). On transthoracic echocardiography, mean pressure gradients decreased from 55.6 ±16.8 mm Hg (pre-TAVI) to 10.3±6.5 mm Hg (in-hospital post-TAVI) (p < 0.001). Five-year survival was 45% and freedom from re-hospitalization for cardiac reasons was 54%. Signs of prosthetic failure were observed in 15 patients (4.2%). The presence of moderate or severe paravalvular regurgitation after TAVI was associated with increased late mortality. The authors concluded that the procedure appears to be an adequate and lasting resolution of aortic stenosis in selected high-risk patients.