Cardiology

Ailawadi, G., H. L. Chang, P. T. O’Gara, K. O’Sullivan, Y. J. Woo, J. J. DeRose, Jr., M. K. Parides, V. H. Thourani, S. Robichaud, A. M. Gillinov, W. C. Taddei-Peters, M. A. Miller, L. P. Perrault, R. L. Smith, L. Goldsmith, K. A. Horvath, K. Doud, K. Baio, A. C. Gelijns, A. J. Moskowitz, E. Bagiella, J. H. Alexander and A. Iribarne (2017). “Pneumonia after cardiac surgery: Experience of the national institutes of health/canadian institutes of health research cardiothoracic surgical trials network.” J Thorac Cardiovasc Surg 153(6): 1384-1391.

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RATIONALE: Pneumonia remains the most common major infection after cardiac surgery despite numerous preventive measures. OBJECTIVES: To prospectively examine the timing, pathogens, and risk factors, including modifiable management practices, for postoperative pneumonia and estimate its impact on clinical outcomes. METHODS: A total of 5158 adult cardiac surgery patients were enrolled prospectively in a cohort study across 10 centers. All infections were adjudicated by an independent committee. Competing risk models were used to assess the association of patient characteristics and management practices with pneumonia within 65 days of surgery. Mortality was assessed by Cox proportional hazards model and length of stay by a multistate model. MEASUREMENTS AND MAIN RESULTS: The cumulative incidence of pneumonia was 2.4%, 33% of which occurred after discharge. Older age, lower hemoglobin level, chronic obstructive pulmonary disease, steroid use, operative time, and left ventricular assist device/heart transplant were risk factors. Ventilation time (24-48 vs 48 hours HR, 4.67; 95% CI, 2.70-8.08), nasogastric tubes (HR, 1.80; 95% CI, 1.10-2.94), and each unit of blood cells transfused (HR, 1.16; 95% CI, 1.08-1.26) increased the risk of pneumonia. Prophylactic use of second-generation cephalosporins (HR, 0.66; 95% CI, 0.45-0.97) and platelet transfusions (HR, 0.49, 95% CI, 0.30-0.79) were protective. Pneumonia was associated with a marked increase in mortality (HR, 8.89; 95% CI, 5.02-15.75) and longer length of stay of 13.55 +/- 1.95 days (bootstrap 95% CI, 10.31-16.58). CONCLUSIONS: Pneumonia continues to impose a major impact on the health of patients after cardiac surgery. After we adjusted for baseline risk, several specific management practices were associated with pneumonia, which offer targets for quality improvement and further research.

Milojevic, M., S. J. Head, M. J. Mack, F. W. Mohr, M. C. Morice, K. D. Dawkins, D. R. Holmes, Jr., P. W. Serruys and A. P. Kappetein (2017). “Influence of practice patterns on outcome among countries enrolled in the syntax trial: 5-year results between percutaneous coronary intervention and coronary artery bypass graftingdagger.” Eur J Cardiothorac Surg: 2017 May [Epub ahead of print].

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OBJECTIVES: To examine differences among participating countries in baseline characteristics, clinical practice, medication strategies and outcomes of patients randomized to coronary artery bypass grafting and percutaneous coronary intervention in the SYNTAX trial. METHODS: In SYNTAX, centres in 18 different countries enrolled 1800 patients, of which 8 countries enrolled >/=80 patients, what was projected to be a large enough sample size to be included in the analysis. Baseline characteristics, practice patterns and clinical outcomes were compared between the USA ( n = 245), the UK ( n = 267), Italy ( n = 197), France ( n = 208), Germany ( n = 179), Netherlands ( n = 148), Belgium ( n = 91) and Hungary ( n = 83). The remaining patients from other participating countries were pooled together ( n = 382). RESULTS: Five-year results demonstrated significantly different outcomes between countries. After adjustment, percutaneous coronary intervention patients in France had lower rates of major adverse cardiac and cerebrovascular events [hazard ratio (HR) = 0.60, 95% confidence interval (CI) 0.37-0.98], while the incidence of repeat revascularization was higher in Hungary (HR = 1.89, 95% CI 1.14-3.42). Coronary artery bypass grafting showed the lowest rate of repeat revascularization in the UK (HR = 0.32, 95% CI 0.12-0.85). There were numerous differences in the risk profile of patients between participating countries, as well as marked differences in surgical practice across countries in the use of blood cardioplegia (range 3.1-89.0%; P < 0.001), bilateral internal mammary artery usage (range 7.8-68.2%; P < 0.001) and off-pump procedures (range 3.9-44.4%; P < 0.001). Variation was also found for percutaneous coronary intervention in the number of implanted stents (range 4.0 +/- 2.3 to 6.1 +/- 2.6; P < 0.001) as well as for the entire stents length (range 69.0 +/- 45.1 to 124.1 +/- 60.9; P < 0.001). Remarkable differences were observed in the prescription of post-coronary artery bypass grafting medication in terms of acetylsalicylic acid (range 79.6-95.0%; P = 0.004), thienopyridine (6.8-31.1%; P < 0.001) and statins (41.3-89.1%; P < 0.001). CONCLUSIONS: Patient characteristics and clinical patterns are significantly different between countries, resulting in significantly different 5-year outcomes. This article presents specific data that can further improve outcomes in each country.

Packer, M., B. Pitt, J. L. Rouleau, K. Swedberg, D. L. DeMets and L. Fisher (2017). “Long-term effects of flosequinan on the morbidity and mortality of patients with severe chronic heart failure: Primary results of the profile trial after 24 years.” JACC Heart Fail 5(6): 399-407.

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OBJECTIVES: The purpose of this clinical trial was to evaluate the long-term effects of flosequinan on the morbidity and mortality of patients with severe chronic heart failure. BACKGROUND: Flosequinan was the first oral vasodilator to be used in the clinic to augment the effects of digitalis, diuretics, and angiotensin-converting enzyme inhibitors in heart failure. However, the drug activated neurohormonal systems and exerted both positive inotropic and chronotropic effects, raising concerns about its safety during long-term use. METHODS: Following a run-in period designed to minimize the risk of tachycardia, we randomly assigned 2,354 patients in New York Heart Association functional class III to IV heart failure and with an ejection fraction

Busse, L. W., X. S. Wang, D. M. Chalikonda, K. W. Finkel, A. K. Khanna, H. M. Szerlip, D. Yoo, S. L. Dana and L. S. Chawla (2017). “Clinical experience with iv angiotensin ii administration: A systematic review of safety.” Crit Care Med: 2017 May [Epub ahead of print].

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OBJECTIVE: Angiotensin II is an endogenous hormone with vasopressor and endocrine activities. This is a systematic review of the safety of IV angiotensin II. DATA SOURCES: PubMed, Medline, Scopus, and Cochrane. STUDY SELECTION: Studies in which human subjects received IV angiotensin II were selected whether or not safety was discussed. DATA EXTRACTION: In total, 18,468 studies were screened by two reviewers and one arbiter. One thousand one hundred twenty-four studies, in which 31,281 participants received angiotensin II (0.5-3,780 ng/kg/min), were selected. Data recorded included number of subjects, comorbidities, angiotensin II dose and duration, pressor effects, other physiologic and side effects, and adverse events. DATA SYNTHESIS: The most common nonpressor effects included changes in plasma aldosterone, renal function, cardiac variables, and electrolytes. Adverse events were infrequent and included headache, chest pressure, and orthostatic symptoms. The most serious side effects were exacerbation of left ventricular failure in patients with congestive heart failure and bronchoconstriction. One patient with congestive heart failure died from refractory left ventricular failure. Refractory hypotensive shock was fatal in 55 of 115 patients treated with angiotensin II in case studies, cohort studies, and one placebo-controlled study. One healthy subject died after a pressor dose of angiotensin II was infused continuously for 6 days. No other serious adverse events attributable to angiotensin II were reported. Heterogeneity in study design prevented meta-analysis. CONCLUSION: Adverse events associated with angiotensin II were infrequent; however, exacerbation of asthma and congestive heart failure and one fatal cerebral hemorrhage were reported.

Webb, J. G., M. J. Mack, J. M. White, D. Dvir, P. Blanke, H. C. Herrmann, J. Leipsic, S. K. Kodali, R. Makkar, D. C. Miller, P. Pibarot, A. Pichard, L. F. Satler, L. Svensson, M. C. Alu, R. M. Suri and M. B. Leon (2017). “Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: Partner 2 valve-in-valve registry.” J Am Coll Cardiol 69(18): 2253-2262.

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BACKGROUND: Early experience with transcatheter aortic valve replacement (TAVR) within failed bioprosthetic surgical aortic valves has shown that valve-in-valve (VIV) TAVR is a feasible therapeutic option with acceptable acute procedural results. OBJECTIVES: The authors examined 30-day and 1-year outcomes in a large cohort of high-risk patients undergoing VIV TAVR. METHODS: Patients with symptomatic degeneration of surgical aortic bioprostheses at high risk (>/=50% major morbidity or mortality) for reoperative surgery were prospectively enrolled in the multicenter PARTNER (Placement of Aortic Transcatheter Valves) 2 VIV trial and continued access registries. RESULTS: Valve-in-valve procedures were performed in 365 patients (96 initial registry, 269 continued access patients). Mean age was 78.9 +/- 10.2 years, and mean Society of Thoracic Surgeons score was 9.1 +/- 4.7%. At 30 days, all-cause mortality was 2.7%, stroke was 2.7%, major vascular complication was 4.1%, conversion to surgery was 0.6%, coronary occlusion was 0.8%, and new pacemaker insertion was 1.9%. One-year all-cause mortality was 12.4%. Mortality fell from the initial registry to the subsequent continued access registry, both at 30 days (8.2% vs. 0.7%, respectively; p = 0.0001) and at 1 year (19.7% vs. 9.8%, respectively; p = 0.006). At 1 year, mean gradient was 17.6 mm Hg, and effective orifice area was 1.16 cm2, with greater than mild paravalvular regurgitation of 1.9%. Left ventricular ejection fraction increased (50.6% to 54.2%), and mass index decreased (135.7 to 117.6 g/m2), with reductions in both mitral (34.9% vs. 12.7%) and tricuspid (31.8% vs. 21.2%) moderate or severe regurgitation (all p < 0.0001). Kansas City Cardiomyopathy Questionnaire score increased (mean: 43.1 to 77.0) and 6-min walk test distance results increased (mean: 163.6 to 252.3 m; both p < 0.0001). CONCLUSIONS: In high-risk patients, TAVR for bioprosthetic aortic valve failure is associated with relatively low mortality and complication rates, improved hemodynamics, and excellent functional and quality-of-life outcomes at 1 year.