ALERT!
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
Selzman and colleagues provide an outstanding overview of the state of the art of bridge to recovery, describing a paradigm shift that has been occurring. A consistent theme over the years is that recovery likelihood is enhanced in younger patients, those with non-ischemic cardiomyopathy, and those who have had HF for shorter durations. Although the INTERMACS database reflects that only about 1% of patients are successfully bridged to recovery, several studies have demonstrated that more patients may be recovered if a proactive approach is undertaken. Such an approach necessarily includes the early identification of potential candidates for removal, the modification of the surgical approach to facilitate later device removal, an active surveillance program, the institution of intensive adjuvant medical therapy, the adoption of standardized weaning protocols, and further exploration of less invasive techniques for removal. The authors effectively argue that only with a wholesale expansion of such a paradigm shift will more patients be successfully weaned. The devil--of course--lays in the details. The ongoing RESTAGE-HF trial will hopefully elucidate some of these details.
The authors describe an alternative technique for insertion of a temporary RVAD so as to allow minimally invasive removal without sternotomy after RV recovery. An elongated graft is sewn to the PA and exited in the subxyphoid area at a site that is separate from the sternotomy incision. After exiting, the graft is attached to an outflow cannula. Inflow from the RA is accessed via a long cannula inserted percutaneously in the femoral vein. At the time of RVAD removal, the graft is exposed in the subxyphoid space, where it is transected, ligated, and returned to the chest. The femoral cannula is removed from the groin and pressue held at its entry site until hemostasis is achieved.
Innovative ways of allowing removal of a temporary RVAD without the need for sternotomy are of great value. Surgeons should have these tools in their armamentarium. Importantly, there are percutaneous RVADs on the horizon that may ultimately allow RVAD removal without necessarily a return trip to the OR. Innovation and technology are playing a central role in rendering MCS surgery less invasive and therefore safer.
The authors of this article aimed to describe survival and clinical outcomes beyond 30 years of follow-up after surgical repair of Tetralogy of Fallot. They found a survival of 72% after 40 years. Health status was comparable to the Dutch population. Factors that were associated with late mortality included: a prior shunt operation, low temperature during surgery and early postoperative arrhythmias. They conclude that although many patients needed reoperation or developed arrhythmias, long-term survival was good, as was health status.
This study was conducted in 94 lung adenocarcinoma patients matching pairs from current, former and never smokers' lung adenocarcinoma and non-malignant lung parenchymal tissue. Investigators discovered different smoking-specific microRNA differences. These findings may explain distinct tumorigenic processes influenced by different smoking and non-smoking expositions.
CMS determined that the evidence of benefit for CT screening for lung cancer is sufficient to permit this as an annual benefit for Medicare and Medicaid recipients in the US. The availability of such coverage will be limited, however, by the need to have the screening as part of a comprehensive counseling (smoking cessation, etc) visit with qualified physicians or non-physician practitioners. Radiologists and imaging centers must meet specific criteria, and activity must be submitted to a registry.
This study explored financial conflicts of interest (FCOI) among authors of published guidelines and consensus statements and their relationship to endorsement of specific drugs. 93% of recent articles reported FCOI status. Of articles publishing funding sources, 65% reported partial or full industry funding. Endorsement of chemotherapeutic agents was strongly associated with FCOIs (p=0.001).
Differentiating a primary lung cancer from an intrapulmonary metastasis can be challenging. The authors developed a lineage test using whole genome amplification and next-generation sequencing to identify breakpoints in known primary tumors and known metastases. Independent primary tumors did not share any genomic rearrangements, whereas primary tumors and their known metastases all had shared rearrangements. This type of analysis may enable pathologists to distinguish primary lung tumors from intrapulmonary mets.
The authors explored a sample of Medicare patients who survived sepsis during hospitalization to assess the impact of afib developing during sepsis on long-term outcomes. Of nearly 139,000 sepsis survivors, 7% had new onset afib during sepsis. Of those pts, 55% were found to have afib after hospitlization. New onset afib during sepsis was associated with increased risks of subsequent heart failure, stroke, and death.
The effects of exercise, increasing pump speed, or both on invasive hemodynamics in centrifugal flow LVAD patients were analyzed in this small study. Findings included:
- Increasing pump speed at rest increased pump flow and decreased PCWP.
- Exercise increased pump flow but yielded increased right and left-sided filling pressures.
- Exercise combined with increased pump speed increased pump flow further (synergistic effect) without lowering right- and left-sided filling pressures.
Questions raised:
- What should be done to improve unloading in LVAD patients during exercise?
- Should algorithms be included in the LVAD that automatically uptitrate RPMs during exercise?
- Would increasing pump speeds further, beyond manufacturer's recommendations, safely improve unloading during exercise?
The correlation between "field independence"--i.e., the ability to ignore distracting visual stimuli--and surgical skills was examined in this simulator model. Resident participants, after undergoing field dependence testing, were asked to place curved needles in a mitral valve model at 10 premarked sites. The residents were assessed on their ability to load the needle on the driver at the appropriate angle. The accuracy of needle loading correlated significantly with the relative field independence of the residents.
Questions:
1. If this methodology is validated in a larger study, would it prove useful in resident training?
2. How about as a factor in resident selection?