Cardiology

Goldsweig, A. M., H. J. Tak, L. W. Chen, H. D. Aronow, B. Shah, D. S. Kolte, P. Velagapudi, N. Desai, M. Szerlip and J. D. Abbott (2019). “The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy.” Am J Cardiol Jun 7. [Epub ahead of print].

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Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Gaudino, M., D. J. Angiolillo, A. Di Franco, D. Capodanno, F. Bakaeen, M. E. Farkouh, S. E. Fremes, D. Holmes, L. N. Girardi, S. Nakamura, S. J. Head, S. J. Park, M. Mack, P. W. Serruys, M. Ruel, G. W. Stone, D. Y. Tam, M. Vallely and D. P. Taggart (2019). “Stroke After Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention: Incidence, Pathogenesis, and Outcomes.” J Am Heart Assoc 8(13): e013032. Epub 2019 Jun 27.

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Stroke carries high short‐ and long‐term mortality and significantly adversely affects quality of life after both CABG and PCI. In an era in which practice guidelines endorse fully informing patients of the available treatment options and actively including them in the decision‐making process, defining the risk of stroke, both acute and long term, and its clinical implications is of paramount importance. CABG carries higher perioperative risk of stroke but provides greater long‐term freedom from recurrent ischemic coronary events and better survival, especially in the patients with most severe disease.2 Percutaneous revascularization is feasible in many patients and is associated with relatively low stroke rates, but this benefit needs to weighed against the higher rates of long‐term mortality and myocardial infarction, particularly in some categories of patients with diabetes mellitus and/or extensive multivessel disease. Indeed, better understanding the size of an injury deriving from a stroke with the 2 available revascularization approaches and the significance of silent brain lesions or neurocognitive changes that may occur would inform the decision‐making process. However, data on these measures (e.g., serial brain imaging) are lacking. A number of measures can be considered to reduce neurological risk in patients undergoing revascularization. For surgery, pre‐ and intraoperative screening of the ascending aorta and optimization of cerebral perfusion pressure based on continuous monitoring are important measures to minimize stroke risk. The use of the anaortic technique has the potential to minimize stroke risk during CABG. Given its technical complexity, specific training is required, ideally in the context of a new CABG subspecialty. Other technical advancements (e.g., embolic protection) warrant investigation to reduce the perioperative risk of stroke in patients undergoing CABG. For PCI, the reduction in mortality and bleeding—with some data also showing a reduction in peri-procedural stroke—associated with radial access potentially makes this approach the vascular access of choice. Regardless of vascular access, operator experience and competency play key roles in minimizing catheter‐induced trauma to the aortic wall and cerebral embolization. Other important measures include optimal anticoagulation and avoidance of air embolism with adequate flushing and connections to the manifold. Routine use of manual thrombectomy in ST‐segment–elevation myocardial infarction should be avoided; if required, adequate catheter engagement should be maintained to avoid embolization of thrombotic material. Finally, IABP and hemodynamic support devices in general should be used with caution, particularly in patients with diffuse atherosclerotic aortic disease. (Excerpt from text, p. e013032, 8-9; no abstract available.)

Blankenship, J. C., J. W. Choi, T. S. Das, P. M. McElgunn, D. Mukherjee, L. L. Paxton, R. Piana, J. R. Sauer, C. J. White and P. L. Duffy (2019). “SCAI/ACVP expert consensus statement on cardiovascular catheterization laboratory economics: If the cath lab is your home you should understand its finances.This statement was endorsed by the Alliance of Cardiovascular Professionals (ACVP) in April 2019.” Catheter Cardiovasc Interv 94(1): 123-135.

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This article is intended for any physician, administrator, or cardiovascular catheterization laboratory (CCL) staff member who desires a fundamental understanding of finances and economics of CCLs in the United States. The authors’ goal is to illuminate general economic principles of CCL operations and provide details that can be used immediately by CCL leaders. Any article on economics in medicine should start by acknowledging the primacy of the principles of medical ethics. While physicians have been trained to act in the best interests of their patients and avoid actions that would harm patients it is vitally important that all professionals in the CCL focus on patients’ needs. Caregivers both at the bedside and in the office must consider how their actions will affect not only the patient they are treating at the time, but others as well. If the best interests of a patient were to conflict with any recommendation in this article, the former should prevail. KEY POINTS: To be successful and financially viable under current payment systems, CCL physicians, and managers must optimize the outcomes and efficiency of care by aligning CCL leadership, strategy, organization, processes, personnel, and culture. Optimizing a CCL’s operating margin (profitability) requires maximizing revenues and minimizing expenses. CCL managers often focus on expense reduction; they should also pay attention to revenue generation. Expense reduction depends on efficiency (on-time starts, short turn-over time, smooth day-to-day schedules), identifying cost-effective materials, and negotiating their price downward. Revenue optimization requires accurate documentation and coding of procedures, comorbidities, and complications. In fee-for-service and bundled payment reimbursement systems, higher volumes of procedures yield higher revenues. New procedures that improve patient care but are expensive can usually be justified by negotiating with vendors for lower prices and including the “halo effect” of collateral services that accompany the new procedure. Fiscal considerations should never eclipse quality concerns. High quality CCL care that prevents complications, increases efficiency, reduces waste, and eliminates unnecessary procedures represents a win for patients, physicians, and CCL administrators.

Baran, D. A., C. L. Grines, S. Bailey, D. Burkhoff, S. A. Hall, T. D. Henry, S. M. Hollenberg, N. K. Kapur, W. O’Neill, J. P. Ornato, K. Stelling, H. Thiele, S. van Diepen and S. S. Naidu (2019). “SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019.” Catheter Cardiovasc Interv 94(1): 29-37.

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BACKGROUND: The outcome of cardiogenic shock complicating myocardial infarction has not appreciably changed in the last 30 years despite the development of various percutaneous mechanical circulatory support options. It is clear that there are varying degrees of cardiogenic shock but there is no robust classification scheme to categorize this disease state. METHODS: A multidisciplinary group of experts convened by the Society for Cardiovascular Angiography and Interventions was assembled to derive a proposed classification schema for cardiogenic shock. Representatives from cardiology (interventional, advanced heart failure, noninvasive), emergency medicine, critical care, and cardiac nursing all collaborated to develop the proposed schema. RESULTS: A system describing stages of cardiogenic shock from A to E was developed. Stage A is “at risk” for cardiogenic shock, stage B is “beginning” shock, stage C is “classic” cardiogenic shock, stage D is “deteriorating”, and E is “extremis”. The difference between stages B and C is the presence of hypoperfusion which is present in stages C and higher. Stage D implies that the initial set of interventions chosen have not restored stability and adequate perfusion despite at least 30 minutes of observation and stage E is the patient in extremis, highly unstable, often with cardiovascular collapse. CONCLUSION: This proposed classification system is simple, clinically applicable across the care spectrum from pre-hospital providers to intensive care staff but will require future validation studies to assess its utility and potential prognostic implications.

Badhwar, V., M. Alkhouli, M. J. Mack, V. H. Thourani and G. Ailawadi (2019). “A pathoanatomic approach to secondary functional mitral regurgitation: Evaluating the evidence.” J Thorac Cardiovasc Surg 158(1): 76-81.

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As evidence to support transcatheter and surgical management of functional secondary mitral regurgitation evolves, targeting therapy to pathoanatomic grade may improve outcomes and the evidence . . . Surgical repair indeed has its niche role in pathoanatomically suitable disease and MV replacement has its place for symptom resolution, although randomized investigation has not been performed to clearly identify survival benefit. Transcatheter repair will clearly have an expanding role in SMR, but successes in some patients and failures in others highlight the need for clarity in how to identify the ideal patients to receive optimal benefit from this modality. Transcatheter MV replacement is undergoing active investigation, but anatomic limitations of LV outflow tract obstruction and annular size may limit its widespread application. Due to the spectrum of structural cardiac disease that accompanies SMR, not all patients can be managed in the same manner and therapy should be tailored . . . In light of the accumulated knowledge from the surgical and transcatheter literature, a simplified pathoanatomic classification scheme of SMR that incorporates the key categories of annular dilatation, LV dysfunction/dilatation and leaflet tethering is proposed. This scoring system may aid in assessing SMR features in outpatient clinics and echocardiography laboratories ( Table 2 ) and assist in tailoring the pathoanatomy to possible therapeutic options based on comorbid risk. This intuitive schema may be useful for future prospective investigation as well as for retrospective examination of both the MITRA-FR echocardiograms as well as the COAPT trial core lab echocardiograms to ascertain if this simple categorization predicts short- and long-term success in transcatheter MV repair. (Excerpts from text, p. 76, 79-80; no abstract available.)