Cardiology

Farzad, A. and J. M. Schussler (2018). “Acute Myopericardial Syndromes.” Cardiol Clin 36(1): 103-114.

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Acute myopericardial syndromes are common but can be challenging to manage and potentially have life-threatening complications. Careful clinical history, physical examination, electrocardiogram interpretation, and application of diagnostic criteria are needed to make an accurate diagnosis, exclude concomitant disease, and properly treat patients. Therapy for acute pericarditis should be guided per the underlying cause. For the most common causes, nonsteroidal antiinflammatory drugs or aspirin with the addition of colchicine remains the mainstay of therapy. Patients with hemodynamic compromise who are resistant to therapy or display high-risk features should prompt hospitalization and initiation of more aggressive and/or invasive therapy.

“Erwin, J. P., 3rd and B. Iung (2018). “Current recommendations for anticoagulant therapy in patients with valvular heart disease and atrial fibrillation: the ACC/AHA and ESC/EACTS Guidelines in Harmony…but not Lockstep!” Heart. Jan 11. [Epub ahead of print].

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From the standpoint of the majority of clinical scenarios, there is great harmonisation between the AHA/ACC and ESC/EACTS valvular guidelines as it pertains to managing the patient with VHD and AF. Both guidelines also point out the importance of using a Valve Team/Heart Valve Centre. This team approach to care is paramount to bridge the areas where there are no guidelines or where the level of evidence (LOE) provides weak guidance in special patient populations. Both groups of authors contend that the term non-valvular atrial fibrillation (NVAF) is poorly defined and should be abandoned. Rather, the clinician should consider AF in the context of each type of specific valvular heart disease (VHD) and in context to specific patient variables.

Friedman, D. J., J. P. Piccini, T. Wang, J. Zheng, S. C. Malaisrie, D. R. Holmes, R. M. Suri, M. J. Mack, V. Badhwar, J. P. Jacobs, J. G. Gaca, S. C. Chow, E. D. Peterson and J. M. Brennan (2018). “Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery.” JAMA 319(4): 365-374.

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Importance: The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. Objective: To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. Design, Setting, and Participants: Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. Exposures: S-LAAO vs no S-LAAO. Main Outcomes and Measures: The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). Results: Among 10524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59). Conclusions and Relevance: Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.

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 Non-Cardiac Surgery in Patients Undergoing Pre-Operative Dobutamine Stress Echocardiography Findings From the Mayo Poce-DSE Investigators.” Am J Med. Jan 15. [Epub ahead of print].

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BACKGROUND: Current guidelines support the use of dobutamine stress echocardiography (DSE) prior to non-cardiac surgery in higher risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated post-operative outcomes of patients in different operative risk categories after pre-operative DSE. METHODS: We collected data from the medical record on 4,494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a non-cardiac surgery. Patients were divided into low, intermediate, and high pre-operative 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% C.I. 0.0% to 3.9%) in the low surgical risk group, 2.1% (95% C.I. 1.6% to 2.5%) in the intermediate surgical risk group, and 3.4% (95% C.I. 2.0% to 4.4%) in the high risk group. Thirty day post-operative 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 non-cardiac 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.

Robertson, J. O., D. C. Naftel, S. L. Myers, R. J. Tedford, S. M. Joseph, J. K. Kirklin and S. C. Silvestry (2018). “Concomitant mitral valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: An INTERMACS database analysis.” J Heart Lung Transplant 37(1): 79-88.

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BACKGROUND: Management of existing mitral valve (MV) disease in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. METHODS: Among continuous-flow LVAD patients with moderate to severe mitral regurgitation entered into the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database between April 2008 and March 2014 (n = 4,930), outcomes were compared between patients who underwent MV repair (MVr, n = 252), MV replacement (MVR, n = 11) and no MV procedure (no MVP, n = 4,667). Impact on survival was analyzed by stratified actuarial and hazard function multivariable methodology. Post-operative functional capacity and quality of life were assessed. RESULTS: Patients who underwent MVPs had higher pre-operative pulmonary vascular resistance (3.6 +/- 2.9 vs 2.9 +/- 2.6 Wood units; p = 0.0006) and higher pulmonary artery systolic pressures (55.1 +/- 13.8 vs 51.5 +/- 14.0 mm Hg; p = 0.0003). Two-year survival was 76% for patients with concomitant MVr, 57% for those with MVR and 71% for those with no MVP (p = 0.15). By multivariable analysis, neither MVr nor MVR affected early or late survival. Although improvements in post-operative functional status as evaluated by 6-minute walk distances were comparable across groups, visual analog score assessments of quality of life suggested a benefit of concomitant MVPs at 1-year post-implant (79.00 +/- 1.73 vs 74.45 +/- 0.51; p = 0.03), with fewer re-admissions observed for MVP patients (p < 0.0001). CONCLUSIONS: Concomitant MVPs are not associated with increased survival overall. However, MVPs are associated with benefits in terms of reduced hospital re-admission and improved quality of life in select patients.