Cardiology

Mack, M. J. and D. R. Holmes, Jr. (2018). “RESPONSE: Heart Team Training Results in Improved Care and Lasting Relationships: Room for Growth.” J Am Coll Cardiol 71(23): 2704-2705.

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The multidisciplinary team-based approach to medical care is, of course, not new. There are numerous examples where specialists from different disciplines have collaborated to deliver integrated, disease-based care. Examples include tumor boards where medical oncologists, radiation therapists, surgeons, and other specialties team together to determine best treatment options for individual patients. The field of organ transplantation also includes a collaborative team-based approach with multiple medical specialties focused on delivering best patient care. The multidisciplinary approach to cardiac care is also not new, as we are reminded by Dr. Robert Frye from the Mayo Clinic that interdisciplinary team-based care was standard practice in the 1950s. After decades of underemployment, the “heart team” has re-emerged over the past decade and a half to create an integrated culture of care for various cardiac diseases . . . One of the benefits of this approach that was not obvious in the early stages, at least to us, was its potential effect on cardiac surgical training. Around the same time as the heart team re-emerged in 2007, a new program for training cardiac surgeons was created. The “I-6” pathway was developed with 2 goals: to shorten the time required to complete surgical training, and to focus the trainees’ experience more on cardiac and thoracic diseases and less on general surgery as in the traditional cardiac surgery training programs. As can be seen from the experience detailed above by Drs. Han and Brown, these 2 paradigm shifts, implementation of the heart team and creation of the I-6 programs, have become synergistic in training the new generation of cardiovascular surgeons. The integrated, team-based approach to patient care as a consequence of the heart team has served as an optimal training platform for the latest generation of cardiac surgeons. However, the authors relate that the benefits have exceeded just the educational experience by creating a cultural environment that has also led to the development of close professional and personal relationships. (Excerpt from text, p. 2704; no abstract available.)

Gaudino, M., M. J. Mack and D. P. Taggart (2018). “Additional Arterial Conduits in Coronary Artery Bypass Surgery: Finally Coming of Age.” J Am Coll Cardiol 71(25): 2974-2976.

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In April 1968, Rene Favaloro published his first description of the coronary artery bypass graft (CABG) surgery. In the 50 years since then, CABG has been arguably the most intensively studied surgical procedure. One of the most important and persistent controversies has been the ideal choice of conduits for revascularization, and in particular, whether the use of multiple arterial grafts leads to significantly improved long-term outcomes. Over the past 5 decades, a substantial amount of observational data reporting the beneficial effects of multiple arterial grafts has been published. The overwhelming majority of series reported a survival advantage, using predominantly either internal thoracic or radial arteries. Notably, even with propensity matching, these studies were almost exclusively based on retrospective observational data, and until < 2 years ago, no adequately powered, comparative, randomized trial had been published. The better outcomes associated with arterial grafts are hypothesized to result from their superior angiographic patency. Randomized trials and a network meta-analysis have consistently shown arterial conduits to have better mid- and long-term patency rates than saphenous vein grafts, providing a likely mechanistic explanation of the improved outcomes associated with the use of arteries. (Excerpt from this editorial; no abstract available.)

Gaudino, M., M. J. Mack and D. P. Taggart (2018). “Additional arterial conduits in coronary artery bypass surgery: Finally coming of age.” J Thorac Cardiovasc Surg Jun 8. [Epub ahead of print].

Full text of this article.

In April 1968, Rene Favaloro published his first description of the coronary artery bypass graft (CABG) surgery. In the 50 years since then, CABG has been arguably the most intensively studied surgical procedure. One of the most important and persistent controversies has been the ideal choice of conduits for revascularization, and in particular, whether the use of multiple arterial grafts leads to significantly improved long-term outcomes. Over the past 5 decades, a substantial amount of observational data reporting the beneficial effects of multiple arterial grafts has been published. The overwhelming majority of series reported a survival advantage, using predominantly either internal thoracic or radial arteries. Notably, even with propensity matching, these studies were almost exclusively based on retrospective observational data, and until < 2 years ago, no adequately powered, comparative, randomized trial had been published. The better outcomes associated with arterial grafts are hypothesized to result from their superior angiographic patency. Randomized trials and a network meta-analysis have consistently shown arterial conduits to have better mid- and long-term patency rates than saphenous vein grafts, providing a likely mechanistic explanation of the improved outcomes associated with the use of arteries. (Excerpt from this editorial; no abstract available.)

Wilson, G., K. Kurian, S. Zamin, J. Urbanczyk, T. Haneke, C. Simonsen, S. Mehta, M. Suresh and J. Michel (2018). “Rates of Echocardiography, Coronary Angiography, and Coronary Intervention Associated With Troponin Testing in Hospitalized Patients.” Am J Cardiol 121(11): 1299-1303.

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Diagnosis of acute myocardial infarction (AMI) often depends on detection of cardiac troponin elevation >99th percentile. However, troponin elevation is commonly found in patients without AMI. We have previously reported an association between troponin elevation and rates of electrocardiogram (ECG), echocardiography (ECHO), and coronary angiography (CAG) in patients with a primary diagnosis of sepsis. We hypothesized that elevated troponin might be associated with greater use of ECHO and CAG in primary diagnoses other than sepsis and that this correlation might also include percutaneous coronary intervention (PCI). We reviewed all inpatient admissions to nine hospitals in Texas in 2016 collecting primary International Statistical Classification of Diseases and Related Health Problems (International Classification of Diseases-10) diagnoses, troponin test data, and the presence of ECHO, CAG, or PCI during hospitalization. We identified 56,895 unique inpatient admissions, of which 14,326 (25.2%) were associated with troponin testing. Of patients tested, 26.1% had one or more troponin I values >/=0.1 ng/ml (99th percentile). Primary ICD-10 diagnoses were grouped into (1) AMI, (2) primary diagnosis other than AMI (non-AMI), (3) congestive heart failure (CHF), (4) sepsis, and (5) Other excluding AMI, CHF, or sepsis. Troponin testing was itself associated with greater utilization of ECHO, CAG, and PCI in all groups except CHF. Troponin I values >/=0.1 ng/ml were associated with increased rates of ECHO, CAG, and PCI across all groups.

Widmer, R. J., M. W. Cullen, B. R. Salonen, K. K. Sundsted, D. Raslau, A. B. Mohabbat, B. M. Dougan, D. M. Bierle, D. K. Lawson, A. J. Widmer, M. Bundrick, P. Gaba, R. Tellez, D. R. Schroeder, R. B. McCully and K. F. Mauck (2018). “Cardiac Events after Noncardiac Surgery in Patients Undergoing Preoperative Dobutamine Stress Echocardiography: Findings From the Mayo Poce-DSE Investigators.” Am J Med 131(6): 702, e715-702, e722.

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BACKGROUND: Current guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. METHODS: We collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. RESULTS: There were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. CONCLUSIONS: These findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of <1%, 1%-5%, and >5% overestimates the actual risk in contemporary settings.