Pre-surgery optimization of patients' expectations to improve outcome in heart surgery: Study protocol of the randomized controlled multi-center PSY-HEART-II trial

The PSY-HEART-I trial indicated that a brief expectation-focused intervention prior to heart surgery improves disability and quality of life 6 months after coronary artery bypass graft surgery (CABG). However, to investigate the clinical utility of such an intervention, a large multi-center trial is needed to generalize the results and their implications for the health care system. The PSY-HEART-II study aims to examine whether a preoperative psychological intervention targeting patients' expectations (EXPECT) can improve outcomes 6 months after CABG (with or without heart valve replacement). EXPECT will be compared to Standard of Care (SOC) and an intervention providing emotional support without targeting expectations (SUPPORT). In a 3-arm multi-center randomized, controlled, prospective trial (RCT), N = 567 patients scheduled for CABG surgery will be randomized to either SOC alone or SOC and EXPECT or SOC and SUPPORT. Patients will be randomized with a fixed unbalanced ratio of 3:3:1 (EXPECT: SUPPORT: SOC) to compare EXPECT to SOC and EXPECT to SUPPORT. Both psychological interventions consist of 2 in-person sessions (à 50 minute), 2 phone consultations (à 20 minute) during the week prior to surgery, and 1 booster phone consultation post-surgery 6 weeks later. Assessment will occur at baseline approx. 3-10 days before surgery, preoperatively the day before surgery, 4-6 days later, and 6 months after surgery. The study's primary end point will be patients' illness-related disability 6 months after surgery. Secondary outcomes will be patients' expectations, subjective illness beliefs, quality of life, length of hospital stay and blood sample parameters (eg, inflammatory parameters such as IL-6, IL-8, CRP). This large multi-center trial has the potential to corroborate and generalize the promising results of the PSY-HEART-I trial for routine care of cardiac surgery patients, and to stimulate revisions of treatment guidelines in heart surgery.

Less loop diuretic use in patients on sacubitril/valsartan undergoing remote pulmonary artery pressure monitoring

AIMS

Control of pulmonary pressures monitored remotely reduced heart failure hospitalizations mainly by lowering filling pressures through the use of loop diuretics. Sacubitril/valsartan improves heart failure outcomes and increases the kidney sensitivity for diuretics. We explored whether sacubitril/valsartan is associated with less utilization of loop diuretics in patients guided with haemodynamic monitoring in the CardioMEMS European Monitoring Study for Heart Failure (MEMS-HF).

METHODS AND RESULTS

The MEMS-HF population (n = 239) was separated by the use of sacubitril/valsartan (n = 68) or no use of it (n = 164). Utilization of diuretics and their doses was prespecified in the protocol and was monitored in both groups. Multivariable regression, ANCOVA, and a generalized linear model were used to fit baseline covariates with furosemide equivalents and changes for 12 months. MEMS-HF participants (n = 239) were grouped in sacubitril/valsartan users [n = 68, 64 ± 11 years, left ventricular ejection fraction (LVEF) 25 ± 9%, cardiac index (CI) 1.89 ± 0.4 L/min/m² ] vs. non-users (n = 164, 70 ± 10 years, LVEF 36 ± 16%, CI 2.11 ± 0.58 L/min/m² , P = 0.0002, P < 0.0001, and P = 0.0015, respectively). In contrast, mean pulmonary artery pressure (PAP) values were comparable between groups (29 ± 11 vs. 31 ± 11 mmHg, P = 0.127). Utilization of loop diuretics was lower in patients taking sacubitril/valsartan compared with those without (P = 0.01). Significant predictor of loop diuretic use was a history of renal failure (P = 0.005) but not age (P = 0.091). After subjects were stratified by sacubitril/valsartan or other diuretic use, PAP was nominally, but not significantly lower in sacubitril/valsartan-treated patients (baseline: P = 0.52; 6 months: P = 0.07; 12 months: P = 0.53), while there was no difference in outcome or PAP changes. This difference was observed despite lower CI (P = 0.0015). Comparable changes were not observed for other non-loop diuretics (P = 0.21).

CONCLUSIONS

In patients whose treatment was guided by remote PAP monitoring, concomitant use of sacubitril/valsartan was associated with reduced utilization of loop diuretics, which could potentially be relevant for outcomes.

Cold atmospheric plasma: a new tool for the treatment of superficial driveline infections

Percutaneous driveline infections (DI) are leading factors for morbidity and mortality in ventricular assist device (VAD) patients. In recent years, cold atmospheric plasma (CAP) has been safely and effectively used in clinical settings to treat topical infections. We describe the first use of CAP to treat a superficial DI. CAP was applied with the kinPen® MED plasma jet device (neoplas tools GmbH, Greifswald, Germany), in the treatment of a DI in a 66-year-old VAD patient in Klinikum Karlsburg, Germany. The patient received a daily application of CAP of 1 min for 12 days. One CAP application was administered each week for 4 weeks in our outpatient clinic after patient discharge. Laboratory tests were conducted and photographs of the driveline exit site were taken. After CAP treatment, the local infection was completely regressed without any signs of exudation or recurrence of the infection. There were no adverse side effects observed, and the HVAD logfile data did not show any abnormalities during treatment. Here, we demonstrate a successful resolution of a VAD DI with the kinPen plasma jet device. We believe that CAP has the potential to be a simple and effective tool in the treatment of superficial DIs.

New insights into bicuspid aortic valve disease: the elongated anterior mitral leaflet

OBJECTIVES

The bicuspid aortic valve (BAV) is associated with various cardiovascular malformations, most predominantly with dilatation of the aortic root and ascending aorta. After sporadic observations of various BAV-associated mitral valve pathologies, we sought to systematically examine the mitral valve morphology in patients with a BAV.

METHODS

Forty-four operated patients with a BAV (type I L/R) and 40 operated patients with a tricuspid aortic valve (TAV) as well as 20 healthy subjects (Normal) were examined by means of transthoracic echocardiography. In all patients, the primary operative indication was aortic valve pathology (stenosis/regurgitation), and no patients with degenerative mitral valve pathology were included.

RESULTS

In patients with a BAV, the anterior mitral leaflet (AML) was significantly elongated in comparison with patients with a TAV and Normal subjects (33.2 ± 6.6 vs 27.7 ± 3.2 vs 27.0 ± 1.9 mm; P < 0.001). Regression analysis revealed that patients with a BAV had significantly elongated AML (P < 0.001) even after correcting for the mitral annulus (MA) diameter and somatometric characteristics (weight, height, body surface area, age). Furthermore, patients with a BAV and concomitant aortic valve insufficiency had significantly elongated AML in comparison with the other groups (35.2 ± 7.6 vs 28.4 ± 3.7 mm; P < 0.001). This difference persisted even after correcting for MA diameter and somatometric differences (P < 0.001). AML heights >32 mm in patients undergoing aortic root/valve procedures were highly predictive of the presence of a BAV [specificity: 90%, positive predictive value: 82%, area under curve: 0.80 (95% CI: 0.71-0.88)].

CONCLUSIONS

We provide evidence that the cardiovascular alterations observed in the BAV are not limited to the aortic valve or ascending aorta but also involve the AML, and seem to be more pronounced in patients with a BAV with concomitant, clinically significant aortic regurgitation.

Influence of crank length and crank width on maximal hand cycling power and cadence

The effect of different crank lengths and crank widths on maximal hand cycling power, cadence and handle speed were determined. Crank lengths and crank widths were adapted to anthropometric data of the participants as the ratio to forward reach (FR) and shoulder breadth (SB), respectively. 25 able-bodied subjects performed maximal inertial load hand cycle ergometry using crank lengths of 19, 22.5 and 26% of FR and 72, 85 and 98% of SB. Maximum power ranged from 754 (246) W for the crank geometry short wide (crank length x crank width) to 873 (293) W for the combination long middle. Every crank length differed significantly (P < 0.05) from each other, whereas no significant effect of crank width to maximum power output was revealed. Optimal cadence decreased significantly (P < 0.001) with increasing crank length from 124.8 (0.9) rpm for the short to 107.5 (1.6) rpm for the long cranks, whereas optimal handle speed increased significantly (P < 0.001) with increasing crank length from 1.81 (0.01) m/s for the short to 2.13 (0.03) m/s for the long cranks. Crank width did neither influence optimal cadence nor optimal handle speed significantly. From the results of this study, for maximum hand cycling power, a crank length to FR ratio of 26% for a crank width to SB ratio of 85% is recommended.

Volumetric assessment of plaque progression with 3-dimensional ultrasonography under statin therapy

BACKGROUND AND PURPOSE

Lowering of serum cholesterol levels with HMG-CoA reductase inhibitors (statins) slowed the progression of atherosclerosis in the carotid arteries in several clinical trials using carotid artery intima media thickness as primary outcome measure. Whereas conventional ultrasonography is limited to thin 2-dimensional image planes, 3-dimensional (3D) ultrasonography provides quantitative measurement of the entire carotid artery plaque volume. This study aims to assess the feasibility of 3D ultrasonography to monitor plaque progression in hypercholesterolemic patients.

METHODS

The authors prospectively assessed the progression of 31 carotid artery plaques over 15.1 +/- 4.5 months in a study of 23 patients (6 women, 17 men; mean age = 61.7 +/- 7.5 years) with hypercholesterolemia under therapy with HMG-CoA reductase inhibitors. All patients were maintained on a lipid-lowering diet. Sixteen patients were additionally treated with statins. Quantitative measurements of carotid artery plaque volumes were performed after 3D reconstruction of exactly parallel transverse duplex ultrasound scans (slice distance = 0.1 mm) into volumetric 3D data sets and segmentation of voxels representing the carotid artery plaque.

RESULTS

Within the treatment group, plaques were significantly less frequently progressive if they had a hypoechoic echogenicity (11%, n = 9 vs 64%, n = 14; P = .016) or if baseline serum cholesterol levels were above 8.0 mmol/L (9%, n = 11 vs 75%, n = 12; P = .002).

CONCLUSION

Three-dimensional ultrasonography extends the measurement of the arterial wall thickness to the 3D volume of an entire atherosclerotic plaque including analysis of its morphology and configuration. However, further clinical trials with an adequate sample size to achieve sufficient statistical power are necessary to assess the effect of statin therapy on plaque progression.

Three-dimensional ultrasound observation of carotid artery plaque ulceration

BACKGROUND AND PURPOSE

Carotid artery plaque ulceration is associated with an increased risk of cerebral embolism. However, because of the rather poor diagnostic quality of conventional 2-D ultrasound and angiography compared with the evaluation of pathological specimens, little information exists on the natural course of carotid plaque ulceration. Recently, the introduction of 3-D ultrasound has made reproducible investigation of plaque morphology possible, providing a reliable plaque surface analysis.

METHODS

We performed 3-D ultrasound examinations of 17 carotid artery plaques with an ulcerated surface in a prospective study of 16 patients (10 men, 6 women; mean+/-SD age 68.9+/-7.1 years) over a mean observation period of 17.6+/-6.3 months. Exactly parallel B-mode ultrasound scans (slice distance 0.1 mm) were acquired with a 5-MHz linear array probe clamped in a carriage device and driven by a mechanical step motor. The recorded images were reconstructed into a volumetric data set in a Cartesian coordinate system.

RESULTS

At the end of the observation period, surface configuration had changed in 4 cases (23.5%). Plaque ulceration regressed in 3 cases, whereas ulcer progression occurred in 1 case. The remaining 13 plaques (76. 5%) showed an unchanged surface configuration.

CONCLUSIONS

Through the use of 3-D ultrasound, it is possible to noninvasively examine the regression and progression of carotid artery plaque ulceration.