Cardiology

Mack, M. J. and E. M. Holper (2016). “Tavr risk assessment: Does the eyeball test have 20/20 vision, or can we do better?” J Am Coll Cardiol 68(4): 353-355.

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The Society of Thoracic Surgeons (STS) analyzed the outcomes of thousands of cardiac operations to develop a risk algorithm. The STS Predicted Risk of Mortality (PROM) predicts 30-day mortality and major morbidity rates after the most common cardiac operations; subsequent studies also showed a correlation with 1-year mortality rates (1). The STS PROM and other risk algorithms, including the European System for Cardiac Operative Risk Evaluation (EuroSCORE), logistic EuroSCORE, and EuroSCORE II, which have been developed and validated in surgical populations, have been used to assess risk in patients considered for transcatheter aortic valve replacement (TAVR). Despite the obvious invalidity of using risk algorithms to assess candidacy for a procedure for which these algorithms were not developed or validated, no alternatives have been available until recently.

McCullough, P. A., A. Afzal and P. Kale (2016). “Goal-directed heart failure care in patients with chronic kidney disease and end-stage renal disease.” JACC Heart Fail 4(8): 662-663.

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Investigators have long recognized that renal function and cardiac performance are integrally linked through hemodynamic, neural, humoral, cell signaling, proteomic, and metabolomic pathways (1). Among risk factors for the development of heart failure (HF), chronic kidney disease (CKD) is the most powerful because it contributes to the three fundamental mechanisms of left ventricular failure: 1) pressure overload; 2) volume overload; and 3) cardiomyopathy (2). When CKD progresses to end-stage renal disease (ESRD), these three mechanisms driving HF become more difficult to control because patients undergoing dialysis have on average higher blood pressures; poor volume control only partially addressed by thrice weekly hemodialysis in most cases; and a well-described form of cardiomyopathy characterized by severe left ventricular hypertrophy, marked cardiac fibrosis, reduced capillary density, and calcific deposits on the mitral and aortic valves (3).

Packer, M. (2016). “The room where it happens: A skeptic’s analysis of the new heart failure guidelines.” J Card Fail: 2016 Jul [Epub ahead of print].

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New heart failure guidelines have been issued during the past several months, both in the US and in Europe, in response to recent advances in and the approval of new drugs for the treatment of heart failure. Although guidelines documents are often viewed as authoritative and purely evidence-based, there are replete with meaningful (and inexplicable) inconsistencies, which derive from a review of the same body of scientific data by different groups. This satirical review highlights several examples of the entertaining foolishness of recent guideline documents in the good-natured hope that physicians will understand what the guidelines are, and more importantly, what they are not. Specifically, this paper describes the emergence of a new non-existent disease; the strange battle between two bradycardic drugs (digoxin and ivabradine); the confusion that reigns over the positioning and dosing of inhibitors of the renin-angiotensin system; and the special recommendations that have been issued for certain special populations. As Otto von Bismarck remarked, guideline deliberations are like sausages; it is better not to see them being made. Yet, even after they are ready for public view, we should be cautious. Practitioners who rely on them for clinical decision-making engage in an unnecessary form of self-deception; those who read them literally and adhere to them strictly do not practice evidence-based medicine; and those who delve into them in a search for the truth are destined to be disappointed.

Dugas, C. M. and J. M. Schussler (2016). “Advanced technology in interventional cardiology: A roadmap for the future of precision coronary interventions.” Trends Cardiovasc Med 26(5): 466-473.

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Several specific new technologies [high-resolution CT coronary imaging with fractional flow reserve (CTCA-FFR), virtual reality (VR), vascular robotic systems (VRS), and three-dimensional printing] are poised to improve the treatment of patients with cardiovascular disease and at the same time the safety of the physicians who care for them. This article focuses on the potential clinical impact each of these modalities will have, as well as speculating on synergies that use of them together may achieve.

Squiers, J. J., B. Lima and J. M. DiMaio (2016). “Contemporary extracorporeal membrane oxygenation therapy in adults: Fundamental principles and systematic review of the evidence.” J Thorac Cardiovasc Surg 152(1): 20-32.

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Extracorporeal membrane oxygenation (ECMO) provides days to weeks of support for patients with respiratory, cardiac, or combined cardiopulmonary failure. Since ECMO was first reported in 1974, nearly 70,000 runs of ECMO have been implemented, and the use of ECMO in adults increased by more than 400% from 2006 to 2011 in the United States. A variety of factors, including the 2009 influenza A epidemic, results from recent clinical trials, and improvements in ECMO technology, have motivated this increased use in adults. Because ECMO is increasingly becoming available to a diverse population of critically ill patients, we provide an overview of its fundamental principles and a systematic review of the evidence basis of this treatment modality for a variety of indications in adults.