Sex-Specific Disparities in Clinical Outcomes After Transcatheter Aortic Valve Replacement Among Different Racial Populations

Background

Sex-related disparities in clinical outcomes following transcatheter aortic valve replacement (TAVR) and the impact of sex on clinical outcomes after TAVR among different racial groups are undetermined.

Objectives

This study assessed whether sex-specific differences in baseline clinical and anatomical characteristics affect clinical outcomes after TAVR and investigated the impact of sex on clinical outcomes among different racial groups.

Methods

The TP-TAVR (Trans-Pacific TAVR) registry is a multinational cohort study of patients with severe aortic stenosis who underwent TAVR at 2 major centers in the United States and 1 major center in South Korea. The primary outcome was a composite of death from any cause, stroke, or rehospitalization after 1 year.

Results

The incidence of the primary composite outcome was not significantly different between sexes (27.9% in men vs 28% in women; adjusted HR: 0.97; 95% CI: 0.79-1.20). This pattern was consistent in Asian (23.5% vs 23.3%; adjusted HR: 0.99; 95% CI: 0.69-1.41) and non-Asian (30.8% vs 31.6%; adjusted HR: 0.95; 95% CI: 0.72-1.24) cohorts, without a significant interaction between sex and racial group (P for interaction = 0.74). The adjusted risk for all-cause mortality was similar between sexes, regardless of racial group. However, the adjusted risk of stroke was significantly lower in male patients than in female patients, which was more prominent in the non-Asian cohort.

Conclusions

Despite significantly different baseline and procedural characteristics, there were no sex-specific differences in the adjusted 1-year rates of primary composite outcomes and all-cause mortality, regardless of different racial groups. (Transpacific TAVR registry [TP-TAVR]; NCT03826264).

When the economy falters, hearts suffer: Economic recessions as a social determinant of health in cardiovascular emergencies

INTRODUCTION

While the relationships between cardiovascular disease (CVD), stress, and financial strain are well studied, the association between recessionary periods and macroeconomic conditions on incidence of disease-specific CVD emergency department (ED) visits is not well established.

OBJECTIVES

This retrospective observational study aimed to assess the relationship between macroeconomic trends and CVD ED visits.

METHODS

This study uses data from the National Hospital Ambulatory Care Survey (NHAMCS), Federal Reserve Economic Database (FRED), National Bureau of Economic Research (NBER), and CVD groupings from National Vital Statistics (NVS) and Center for Medicare and Medicaid Services (CMS) from 1999 to 2020 to analyze ED visits in relation to macroeconomic indicators and NBER defined recessions and expansions.

RESULTS

CVD ED visits grew by 79.7% from 1999 to 2020, significantly more than total ED visits (27.8%, p < 0.001). A national estimate of 213.2 million CVD ED visits, with 22.9 million visits in economic recessions were analyzed. A secondary group including a 6-month period before and after each recession (defined as a "broadened recession") was also analyzed to account for potential leading and lagging effects of the recession, with a total of 50.0 million visits. A significantly higher proportion of CVD ED visits related to heart failure (HF) and other acute ischemic heart diseases (IHD) was observed during recessionary time periods both directly and with a 6-month lead and lag (p < 0.05). The proportion of aortic aneurysm and dissection (AAA) and atherosclerosis (ASVD) ED visits was significantly higher (p = 0.024) in the recession period with a 6-month lead and lag. When controlled for common demographic factors, economic approximations of recession such as the CPI, federal funds rate, and real disposable income were significantly associated with increased CVD ED visits.

CONCLUSION

Macroeconomic trends have a significant relationship with the overall mix of CVD ED visits and represent an understudied social determinant of health.

Echocardiographic parameters associated with less reverse left ventricular remodeling after transcatheter aortic valve implant in subjects with prosthesis patient mismatch

BACKGROUND

Transaortic valve implant (TAVI) is the treatment of choice for severe aortic stenosis (AS). Some patients develop prosthesis patient mismatch (PPM) after TAVI. It is challenging to determine which patients are at risk for clinical deterioration.

METHODS

We retrospectively measured echocardiographic parameters of left ventricular (LV) morphology and function, prosthetic aortic valve effective orifice area (iEOA) and hemodynamics in 313 patients before and 1 year after TAVI. Our objective was to compare the change in echocardiographic parameters associated with left ventricular reverse modeling in subjects with and without PPM. Our secondary objective was to evaluate echo parameters associated with PPM and the relationship to patient functional status and survival post-TAVI.

RESULTS

We found that 82 (26.2%) of subjects had moderate and 37 (11.8%) had severe PPM post-TAVI. There was less relative improvement in LVEF with PPM (1.9 ± 21.3% vs. 8.2 + 30.1%, p = .045). LV GLS also exhibited less relative improvement in those with PPM (13.4 + 34.1% vs. 30.9 + 73.3%, p = .012). NYHA functional class improved in 84.3% of subjects by one grade or more. Echocardiographic markers of PPM were worse in those without improvement in NYHA class (mean AT/ET was .29 vs. .27, p = .05; DVI was .46 vs. .51, p = .021; and iEOA was .8 cm/m2 vs. .9 cm/m2 , p = .025). There was no association with PPM and survival.

CONCLUSIONS

There was no improvement in LVEF and less improvement in LV GLS in those with PPM post-TAVI. Echocardiographic markers of PPM were present in those with lack of improvement in NYHA functional class.

Valvular and ascending aortic hemodynamics of the On-X aortic valved conduit by same-day echocardiography and 4D flow MRI

This study aims to assess whether the On-X aortic valved conduit better restores normal valvular and ascending aortic hemodynamics than other commonly used bileaflet mechanical valved conduit prostheses from St. Jude Medical and Carbomedics by using same-day transthoracic echocardiography (TTE) and 4D flow magnetic resonance imaging (MRI) examinations. TTE and 4D flow MRI were performed back-to-back in 10 patients with On-X, six patients with St. Jude (two) and Carbomedics (four) prostheses, and 36 healthy volunteers. TTE evaluated valvular hemodynamic parameters: transvalvular peak velocity (TPV), mean and peak transvalvular pressure gradient (TPG), and effective orifice area (EOA). 4D flow MRI evaluated the peak systolic 3D viscous energy loss rate (VELR) density and mean vorticity magnitude in the ascending aorta (AAo). While higher TPV and mean and peak TPG were recorded in all patients compared to healthy subjects, the values in On-X patients were closer to those in healthy subjects (TPV 1.9 ± 0.3 vs. 2.2 ± 0.3 vs. 1.2 ± 0.2 m/s, mean TPG 7.4 ± 1.9 vs. 9.2 ± 2.3 vs. 3.1 ± 0.9 mmHg, peak TPG 15.3 ± 5.2 vs. 18.9 ± 5.2 vs. 6.1 ± 1.8 mmHg, p < 0.001). Likewise, while higher VELR density and mean vorticity magnitude were recorded in all patients than in healthy subjects, the values in On-X patients were closer to those in healthy subjects (VELR: 50.6 ± 20.1 vs. 89.8 ± 35.2 vs. 21.4 ± 9.2 W/m3, p < 0.001) and vorticity (147.6 ± 30.0 vs. 191.2 ± 26.0 vs. 84.6 ± 20.5 s-1, p < 0.001). This study demonstrates that the On-X aortic valved conduit may produce less aberrant hemodynamics in the AAo while maintaining similar valvular hemodynamics to St. Jude Medical and Carbomedics alternatives.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Novel mesh suture may resist bone cutting seen with wire-based sternal closures

OBJECTIVE

Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution.

METHODS

Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force.

RESULTS

All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07).

CONCLUSIONS

Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.

Conformational changes during in vitro balloon fracture of internal aortic annuloplasty ring

OBJECTIVE

HAART 300 300 (BioStable Science and Engineering, Inc) aortic annuloplasty rings restore physiologic annular geometry during aortic valve repair. Transcatheter valve-in-ring implantation is appealing for recurrent valve dysfunction but may necessitate balloon fracture of downsized annuloplasty rings. We characterized the feasibility of ring fracture and changes in ring geometry preceding fracture.

METHODS

The 19-mm, 21-mm, and 23-mm HAART 300 annuloplasty rings were obtained, and 23-mm, 24-mm, 25-mm, and 26-mm valvuloplasty balloons were obtained. Under continuous fluoroscopy and video recording, a 23-mm balloon was inflated within a 19-mm ring at 1 atm/s until ring fracture or balloon failure occurred. If balloon failure occurred, experiments were sequentially repeated with 1-mm upsized balloons until ring fracture occurred or no larger-sized balloons were available.

RESULTS

Upon balloon inflation, all rings exhibited an irreversible conformational change from an elliptical, annular geometry to a circular shape with ring posts flaring outward. A 23-mm balloon burst at 21 atm without fracturing the 19-mm ring. The 24-mm balloon fractured the 19-mm ring at 15 atm. Likewise, a 24-mm balloon ruptured at 18 atm without fracturing the 21-mm annuloplasty ring. A 25-mm balloon fractured the 21-mm ring at 18 atm. Finally, a 26-mm balloon burst at 20 atm without fracturing a 23-mm annuloplasty ring, but it did elicit the confirmational changes described. All fractures occurred along the upslope of a ring post. The exposed metal frame was visible after the 21-mm ring fracture.

CONCLUSIONS

Fracture of HAART 300 aortic annuloplasty rings is possible with an oversized, high-pressure balloon. However, the geometrical changes in the ring and subsequent rupture of its fabric covering may be obstacles to safe, in vivo ring fracture.

Characterization of Screen Failures Among Patients Evaluated for Transcatheter Tricuspid Valve Repair (TriSelect-Study)

BACKGROUND

Transcatheter tricuspid valve repair (TTVr) has significantly expanded treatment options for tricuspid regurgitation (TR). However, a sizeable proportion of patients are still declined for TTVr and little is known about their clinical characteristics and cardiac morphology.

OBJECTIVES

This study sought to characterize patients who screen fail for TTVr with respect to their clinical characteristics and cardiac morphology.

METHODS

A total of 547 patients were evaluated for TTVr between January 2016 to December 2021 from 3 centers in the United States and Germany. Clinical records and echocardiographic studies were used to assess medical history and right ventricular (RV) and tricuspid valve (TV) characteristics.

RESULTS

Median age was 80 (IQR: 74-83) years and 60.0% were female. Over half (58.1%) were accepted for TTVr. Of those who were deemed unsuitable for TTVr (41.9%), the most common exclusion reasons were anatomical criteria (56.8%). In the regression analysis, RV and right atrial size, TV coaptation gap, and tethering area were identified as independent screen failure predictors. Other rejection reasons included clinical futility (17.9%), low symptom burden (12.7%), and technical limitations (12.7%). Most of the excluded patients (71.6%) were managed conservatively with medical therapy, while a small number either proceeded to TV surgery (22.3%) or subsequently became eligible for transcatheter tricuspid valve replacement in later available clinical trials in the United States (6.1%).

CONCLUSIONS

The majority of TTVr screen failure patients are excluded due to TV, right atrial, and RV enlargement. However, a significant proportion is excluded due to clinical futility. These identifiable anatomical and clinical characteristics emphasize the importance of earlier referral and intervention of TR and the need for continued innovation of Transcatheter tricuspid valve interventions.

Race-Specific Impact of Conventional Surgical Risk Score on 1-Year Mortality After Transcatheter Aortic Valve Replacement

Background

Interracial differences in the distribution and prognostic value of conventional Society of Thoracic Surgeons (STS) score on long-term mortality after transcatheter aortic valve replacement (TAVR) are uncertain.

Objectives

This study aims to compare the impact of STS scores on clinical outcomes at 1-year after TAVR between Asian and non-Asian populations.

Methods

We used the Trans-Pacific TAVR (TP-TAVR) registry, a multinational multicenter, observational registry involving patients undergoing TAVR at 2 major centers in the United States and 1 major center in Korea. Patients were classified into 3 groups (low, intermediate, and high-risk) according to the STS score and compared between STS risk groups and race. The primary outcome was all-cause mortality at 1-year.

Results

Among 1,412 patients, 581 were Asian and 831 were non-Asian. The distribution of the STS risk score group was different between Asian and non-Asian groups (62.5% low-, 29.8% intermediate-, and 7.7% high-risk in Asian vs 40.6% low-, 39.1% intermediate-, and 20.3% high-risk in non-Asian). In the Asian population, the all-cause mortality at 1-year was substantially higher in the high-risk STS group than in the low- and intermediate-risk groups (3.6% low-risk, 8.7% intermediate-risk, and 24.4% high-risk; log-rank P < 0.001), which was primarily driven by noncardiac mortality. In the non-Asian group, there was a proportional increase in all-cause mortality at 1-year according to the STS risk category (5.3% low-risk, 12.6% intermediate-risk, and 17.8% high-risk; log-rank P < 0.001).

Conclusions

In this multiracial registry of patients with severe aortic stenosis who underwent TAVR, we identified a differential proportion and prognostic impact of STS score on 1-year mortality between Asian and non-Asian patients (TP-TAVR [Transpacific TAVR Registry]; NCT03826264).

Inter-racial differences in patients undergoing transcatheter aortic valve implantation

OBJECTIVE

Little information exists about inter-racial differences in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). We investigated whether differences in baseline characteristics between Asian and non-Asian population may contribute to disparities in clinical outcomes after TAVI.

METHODS

We performed a registry-based, multinational cohort study of patients with severe AS who underwent TAVI at two centres in the USA and one centre in South Korea. The primary outcome was a composite of death, stroke or rehospitalisation at 1 year.

RESULTS

Of 1412 patients, 581 patients were Asian and 831 were non-Asian (87.5% white, 1.7% black, 6.1% Hispanic or 4.7% others). There were substantial differences in baseline characteristics between two racial groups. The primary composite outcome was significantly lower in the Asian group than in the non-Asian group (26.0% vs 35.0%; HR 0.73; 95% CI 0.59 to 0.89; p=0.003). However, after adjustment of baseline covariates, the risk of primary composite outcome was not significantly different (HR 0.79; 95% CI 0.60 to 1.03; p=0.08). The all-cause mortality at 1 year was significantly lower in the Asian group than the non-Asian group (7.4% vs 12.5%; HR 0.60; 95% CI 0.41 to 0.88; p=0.009). After multivariable adjustment, the risk of all-cause mortality was also similar (HR 1.17; 95% CI 0.73 to 1.88; p=0.52).

CONCLUSIONS

There were significant differences in baseline and procedural factors among Asian and non-Asian patients who underwent TAVI. Observed inter-racial differences in clinical outcomes were largely explained by baseline differences in clinical, anatomical and procedural factors.

TRIAL REGISTRATION NUMBER

NCT03826264 (https://wwwclinicaltrialsgov).

Racial Differences in the Incidence and Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to compare the incidence and prognostic significance of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) according to racial groups.

BACKGROUND

PPM after TAVR may be of more concern in Asian populations considering their relatively small annular and valve sizes compared with Western populations.

METHODS

TP-TAVR (Transpacific TAVR Registry) was an international multicenter cohort study of patients with severe aortic stenosis who underwent TAVR in the United States and South Korea from January 2015 to November 2019. PPM was defined as moderate (0.65-0.85 cm²/m²) or severe (<0.65 cm²/m²) at the indexed effective orifice area. The primary outcome was a composite of death, stroke, or rehospitalization at 1 year.

RESULTS

Among 1,101 eligible patients (533 Asian and 569 non-Asian), the incidence of PPM was significantly lower in the Asian population (33.6%; moderate, 26.5%; severe, 7.1%) than in the non-Asian population (54.5%; moderate, 29.8%; severe, 24.7%). The 1-year rate of the primary outcome was similar between the PPM and non-PPM groups (27.5% vs 28.1%; P = 0.69); this pattern was consistent between Asian (25.4% vs 25.2%; P = 0.31) and non-Asian (28.7% vs 32.1%; P = 0.97) patients. After multivariable adjustment, the risk for the primary outcome did not significantly differ between the PPM and non-PPM groups in the overall population (HR: 0.95; 95% CI: 0.74-1.21), in Asian patients (HR: 1.07; 95% CI: 0.74-1.55), and in non-Asian patients (HR: 0.86; 95% CI: 0.63-1.19).

CONCLUSIONS

In this study of patients with severe aortic stenosis who underwent TAVR, the incidence of PPM was significantly lower in Asian patients than in non-Asian patients. The 1-year risk for the primary composite outcome was similar between the PPM and non-PPM groups regardless of racial group. (Transpacific TAVR Registry [TP-TAVR]; NCT03826264).

Temporal trends in right heart strain in patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

BACKGROUND

Pulmonary thromboendarterectomy (PTE) is a curative procedure for chronic thromboembolic pulmonary hypertension (CTEPH). Right ventricular free wall strain (RV FWS) and right atrial strain (RAS) are not well studied in a CTEPH population. We sought to determine temporal trends in RAS and RV FWS in patients post-PTE.

METHODS

28 patients undergoing PTE for CTEPH were prospectively enrolled in a surgical database. Comprehensive echocardiographic assessment of the right heart was performed including RV FWS, right atrial volume, and the three components of RAS: reservoir, conduit, and booster strain.

RESULTS

Patients undergoing PTE demonstrated improvement in NYHA functional class (P < 0.001). Hemodynamic assessment showed improvement in mean pulmonary artery pressure from 49.7 ± 8.5 mm Hg to 23.9 ± 6.5 mm Hg (P < 0.001) and pulmonary vascular resistance decreased from 7.8 ± 3.2 wu to 2.4 ± 1.3 wu (P < 0.001). Tricuspid annular plane systolic excursion (TAPSE) and lateral S` declined immediately post-op. RV FWS improved from -14.4 ± 4% to -19 ± 3.4% post-op and -21.2 ± 4.7% at long-term follow-up (P < 0.001). Improvement in RV FWS post-op was driven primarily by increases in the apical and mid segments. RA volume declined significantly during the study period. RA reservoir and conduit strain improved after PTE.

CONCLUSION

Patients undergoing PTE for CTEPH had significant improvement in right heart hemodynamics immediately post-op. Traditional echo metrics of RV performance including TAPSE and lateral S` did not improve. RV FWS improved, which was driven by changes in the apical and mid segments. This highlights that RV FWS is a viable and useful metric to follow in CTEPH patients post-PTE.

Unique technical challenges in patients undergoing TAVR for failed aortic homografts

OBJECTIVE

Surgical reoperation for aortic homograft structural valve degeneration (SVD) is a high-risk procedure. Transcatheter aortic valve replacement (TAVR) for homograft-SVD is an alternative to reoperation, but descriptions of implantation techniques are limited. This study compares outcome in patients undergoing into two groups by the type of previously implanted aortic valve prosthesis: TAVR for failed aortic homografts (TAVR-H) or for stented aortic bioprostheses (TAVR-BP).

METHODS

From 2015 to 2017, TAVR was performed in 41 patients with SVD. Thirty-three patients in the TAVR-BP group (six for SVD of valved conduits), and eight patients in the TAVR-H group. The Valve Academic Research Consortium criteria were used for outcome reporting purposes.

RESULTS

The patients with TAVR-BP had predominant prosthetic stenosis (94%, p = .002), whereas TAVR-H individuals presented mostly with regurgitation (88%, p = <.001). Patients with TAVR-H received: Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Low, 40% ventricular fixation in relation to homograft annulus was attempted to anchor the prosthesis on the homograft suture-line. One patient with TAVR-BP experienced intraoperative distal prosthesis migration and Type-B aortic dissection, and two patients in the TAVR-H group had late postoperative proximal device migration. In both groups, there was zero 30-day mortality, stroke, or pacemaker implantation.

CONCLUSIONS

TAVR for failing aortic homografts may be a feasible and safe alternative to high-risk surgical reintervention. Precise, 40%-ventricular device positioning appears crucial for prevention of late paravalvular leak/late prosthesis migration and minimizing the risk of repeat surgical intervention.

Valve-in-valve-prosthesis embolization and aortic dissection: single procedure, double complication

Transcatheter aortic valve implantation (TAVI) is a recognized treatment method for high-risk patients with aortic stenosis. TAVI is also recommended for structural valve degeneration of a biological valve prosthesis. TAVI-specific complications, such as prosthesis embolization and aortic dissection, are uncommon but potential concerns. A 73-year-old woman presented with structural valve degeneration 14 years after aortic root replacement with a bioprosthetic valved conduit. The patient underwent TAVI valve-in-valve under monitored anaesthesia care. Intraoperatively, the self-expandable prosthesis was difficult to deploy within the valved conduit and ultimately migrated distally. During the technically difficult passage of the prosthesis delivery system through the tortuous aorta, the patient started reporting symptoms suggestive of aortic dissection. An emergency computed tomography scan confirmed type B dissection. Thoracic endovascular aortic repair followed by deployment of a balloon-expandable prosthesis below the self-expandable implant was performed. Careful prosthesis selection in valve-in-valve patients after aortic root replacement is crucial for procedural success.

Limited versus full sternotomy for aortic valve replacement

BACKGROUND

Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity.

OBJECTIVES

To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.

SEARCH METHODS

We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance.

SELECTION CRITERIA

Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table.

MAIN RESULTS

The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I2 = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I2 = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I2 = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses.

AUTHORS' CONCLUSIONS

The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.

Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer

HYPOTHESIS

Patients receiving neoadjuvant chemoradiotherapy followed by surgery (CRS) undergo downstaging of their tumor and have improved survival when compared with patients undergoing surgery followed by adjuvant chemoradiotherapy (SCR).

DESIGN

Retrospective study.

SETTING

Tertiary-care university medical center.

PATIENTS

One hundred twenty-three patients with squamous cell carcinoma and adenocarcinoma of the esophagus underwent Ivor-Lewis esophagectomy from January 1, 1990, through December 31, 2001. Of these, 31 received CRS; 27, SCR; and 65, surgery alone.

INTERVENTIONS

Patients were candidates for neoadjuvant or adjuvant therapy if they had locally advanced disease (T3/T4 N0 or any T stage with N1). Neoadjuvant and adjuvant therapies were nonrandomized and based on the preference of the treating oncologist and surgeon.

MAIN OUTCOME MEASUREMENTS

Pathological downstaging was analyzed in the patients receiving CRS. Operative mortality, postoperative morbidity, median survival, and overall survival were compared between the CRS and SCR groups.

RESULTS

Pathological downstaging (as characterized by TNM staging) was observed in 20 (64%) of the patients receiving CRS. Complete pathological responses occurred in 5 (16%) of the patients undergoing CRS. No 30-day mortality was observed in either treatment group. No statistical difference in survival was observed between groups, although a trend suggested improved survival with neoadjuvant therapy (3-year survival in CRS and SCR groups was 45% and 22%, respectively; P =.15). Complete pathological responders in the CRS group had a 1-year survival of 80% compared with 29% in nonresponders (P =.25). No statistical differences were observed between groups in relation to blood loss, length of hospital stay, mortality, or morbidity.

CONCLUSIONS

Neoadjuvant chemoradiotherapy effectively downstages cancer in patients with locally advanced esophageal disease. Morbidity and operative mortality were not significantly different between patients receiving neoadjuvant and adjuvant therapy. The difference in overall survival between the 2 groups did not reach statistical significance, although a trend at 3 years was observed.

Recurrent ventral herniation in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is an inherited collagen disorder characterized by skin hyperextensibility, joint laxity, and tissue friability. In this study, it was hypothesized that Ehlers-Danlos syndrome is frequently undiagnosed in patients who present for repair of ventral abdominal wall hernias. A retrospective chart review was conducted, and patients who had presented for elective repair of recurrent abdominal wall herniation were identified. In all patients, one or more prior attempts at repair with either mesh or autologous tissues had failed. Patients in whom abdominal wall components were lost secondary to extirpation or trauma, patients who had required acute closure, and patients with less than 2 months of follow-up were excluded. Twenty patients met these criteria. Twenty cases of recurrent ventral hernia repairs were reviewed, with special attention to identification of the preoperative diagnosis of Ehlers-Danlos syndrome. Patients ranged in age from 29 to 75 years, with a mean age of 54 years. Five patients were male (25 percent), and 15 were female (75 percent). The majority (95 percent) were Caucasian. The most common initial procedures were gynecologic in origin (35 percent). A precise closure technique that minimizes recurrence after ventral hernia repairs was used. With use of this technique, there was only one recurrence over a follow-up period that ranged from 2 to 60 months (mean follow-up duration, 25.7 months). Two patients with Ehlers-Danlos syndrome were identified, and their cases are presented in this article. The "components separation" technique with primary component approximation and mesh overlay was used for defect closure in the two cases presented. The identification of these two patients suggests the possibility of underdiagnosis of Ehlers-Danlos syndrome among patients who undergo repeated ventral hernia repair and who have had previous adverse postoperative outcomes. There are no previous reports in the literature that address recurrent ventral abdominal herniation in patients with Ehlers-Danlos syndrome.

In vivo analysis of bacterial biofilm formation on facial plastic bioimplants

OBJECTIVES

This study examines the formation of biofilm on biomaterials commonly used in facial plastics and reconstruction including titanium, silicone, ion-bombarded silicone (Ultrasil), e-PTFE (Gore-Tex), e-PTFE with silver/chlorhexidine (Gore-Tex Plus), and PHDPE (Medpor).

METHODS

These biomaterials were implanted subcutaneously in the dorsum of 11 guinea pigs after contamination with Staphylococcus aureus and examined with scanning electron microscopy after 7 days. Wounds were also inspected for infection and extrusion rates.

RESULTS

Results show biofilm formation on titanium, silicone, ion-bombarded silicone, e-PTFE, and PHDPE associated with high rates of extrusion and infection. Implants of e-PTFE with silver/chlorhexidine, on the other hand, appeared resistant to biofilm formation and demonstrated significantly lower rates of extrusion and infection.

CONCLUSIONS

Contamination of bioimplants in vivo leads to formation of bacterial biofilm on the surface of the biomaterial, causing infection, pus formation, and extrusion. The authors hypothesize that the antiseptic agents impregnated in the biomaterial form a protective coat of silver, chlorhexidine, and inflammatory cells that inhibits initial bacterial adhesion to the biomaterial surface.