Cardiology

Spinelli, D., Weaver, F.A., Azizzadeh, A., Magee, G.A., Piffaretti, G., Benedetto, F., Miller, C.C., Sandhu, H.K., Gable, D.R. and Trimarchi, S. (2021). “Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.” J Thorac Cardiovasc Surg Jan 21;S0022-5223(21)00123-9. [Epub ahead of print].

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OBJECTIVE: The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections. METHODS: Patients from WL Gore’s Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed. RESULTS: Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696). CONCLUSIONS: In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.

Karacsonyi, J., Stanberry, L., Alaswad, K., Krestyaninov, O., Choi, J.W., Rangan, B.V., Nikolakopoulos, I., Vemmou, E., Ungi, I. and Brilakis, E.S. (2021). “Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Intervention: Comparison of 3 Scores.” Circ Cardiovasc Interv 14(1): e009860.

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The success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) significantly increased from 77% between 2000 and 20111 to 85% to 90% currently at experienced centers and depends on center and operator experience and lesion characteristics. Several CTO PCI scoring systems have been developed to assess procedural difficulty. The first one was the Japan chronic total occlusion (J-CTO) score that estimates the likelihood of successful guidewire crossing within the first 30 minutes based on 5 variables: blunt stump, calcification, lesion tortuosity, prior failed attempt, and occlusion length ≥20 mm. Another widely used score is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score that uses 4 angiographic characteristics: moderate/severe proximal vessel tortuosity, proximal cap ambiguity, circumflex coronary artery CTO, and absence of interventional collaterals to predict technical success.The EuroCTO CASTLE score utilizes 6 variables for assessing the likelihood of success: prior Coronary artery bypass graft surgery, age (≥70 years), stump anatomy (blunt or invisible), tortuosity degree (severe or unseen), length of occlusion (≥20 mm), and extent of calcification (>50% of the segment). [No abstract; excerpt from article].

Moreyra, A.E., Cosgrove, N.M., Zinonos, S., Yang, Y., Cabrera, J., Pepe, R.J., Alam, A., Kostis, J.B., Lee, L. and Kostis, W.J. (2021). “Constrictive Pericarditis after Open Heart Surgery: A 20-Year Case Controlled Study.” Int J Cardiol Jan 6;S0167-5273(20)34338-2. [Epub ahead of print].

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BACKGROUND: Constrictive pericarditis is a rare complication of open heart surgery (OHS), but little is known regarding the etiologic determinants, and prognostic factors. The purpose of this study was to investigate clinical predictors and long term prognosis of post-operative constrictive pericarditis (CP). METHODS: Using the Myocardial Infarction Data Acquisition System database, we analyzed records of 142,837 patients who were admitted for OHS in New Jersey hospitals between 1995 and 2015. Ninety-one patients were hospitalized with CP 30 days or longer after discharge from OHS. Differences in proportions were analyzed using Chi square tests. Controls were matched to cases for demographics, surgical procedure type, history of OHS, and propensity score. Cox proportional hazard models were used to evaluate the risk of all-cause death. Log-rank tests and Cox models were used to assess differences in the Kaplan-Meier survival curves with and without adjustments for comorbidities. RESULTS: Patients with CP were more likely to have history of valve disease (VD, p < 0.001), atrial fibrillation (AF, p = 0.024) renal disease (CKD, p = 0.028), hemodialysis (HD, p = 0.008), previous OHS (p < 0.001). Patients with CP compared to matched controls had a higher 7-year mortality (p < 0.001). This difference became statistically significant at 1-year after surgery. CONCLUSION: CP is a rare complication of OHS that occurs more frequently in patients with VD, AF, CKD, HD, multiple OHS, and it is associated with an unfavorable long-term prognosis. Given the large number of OHS performed every year, the results highlight the need for clinicians to recognize and properly manage this complication of OHS.

Gach, R., Triano, S., Ogola, G.O., da Graca, B., Shannon, J., El-Ansary, D., Bilbrey, T., Cortelli, M. and Adams, J. (2021). “”Keep Your Move in the Tube” safely increases discharge home following cardiac surgery.” Pm r Feb 1. [Epub ahead of print].

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INTRODUCTION: Restrictive sternal precautions intended to prevent cardiac surgery patients from damaging healing sternotomies lack supporting evidence and may decrease independence and increase post-acute care utilization. Data regarding the impact of alternative approaches on safety and outcomes are needed to guide evidence-based best practices. OBJECTIVE: To examine whether an approach allowing greater freedom during activities of daily living than permitted under commonly-used restrictive sternal precautions can safely decrease post-acute care utilization. DESIGN: Before-and-after study, using propensity score adjustment to account for differences in patient clinical and demographic characteristics, surgery type, and surgeon. SETTING: 600-bed acute care hospital. INTERVENTION: Beginning March 2016, our institution replaced traditional weight- and time-based precautions given to patients who underwent median sternotomy with the “Keep Your Move in the Tube” (KMIT) approach for mindfully performing movements involved in the activities of daily living, guided by pain. MAIN OUTCOME MEASURES: We compared sternal wound complications, discharge disposition, 30-day readmission, and functional status between consecutive cardiac surgery patients with “independent” or “modified independent” preoperative functional status who underwent median sternotomy in the 1.5 years before (n = 627, standard precautions group) and after (n = 477, KMIT group) KMIT implementation. RESULTS: The odds of discharge to home, vs to inpatient rehabilitation or skilled nursing facility, was ~3 times higher for KMIT than standard precautions patients (risk-adjusted odds ratio [rOR], 95% confidence interval [CI] = 2.90, 1.95-4.32, and 3.03, 1.57-5.86, respectively). KMIT patients also had significantly higher odds of demonstrating “independent” or “modified independent” functional status on final inpatient physical therapy treatment for bed mobility (rOR, 95%CI = 7.51, 5.48-10.30) and transfers (rOR, 95%CI = 3.40, 2.62-4.42). No significant difference was observed in sternal wound complications (in-hospital or causing readmission) (rOR, 95%CI = 1.27, 0.52-3.09) or all-cause 30-day readmissions (rOR, 95%CI = 0.55, 0.23-1.33). CONCLUSIONS: KMIT increases discharge-to-home for cardiac surgery patients without increasing risk for adverse events and reducing utilization of expensive institutional post-acute care.

Saxon, J.T., Cohen, D.J., Chhatriwalla, A.K., Kotinkaduwa, L.N., Kar, S., Lim, D.S., Abraham, W.T., Lindenfeld, J., Mack, M.J., Arnold, S.V. and Stone, G.W. (2020). “Impact of COPD on Outcomes After MitraClip for Secondary Mitral Regurgitation: The COAPT Trial.” JACC Cardiovasc Interv 13(23): 2795-2803.

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OBJECTIVES: The aim of this study was to examine the relationship between chronic obstructive pulmonary disease (COPD) and outcomes after transcatheter mitral valve repair (TMVr) for severe secondary mitral regurgitation. BACKGROUND: TMVr with the MitraClip improves clinical and health-status outcomes in patients with heart failure and severe (3+ to 4+) secondary mitral regurgitation. Whether these benefits are modified by COPD is unknown. METHODS: COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) was an open-label, multicenter, randomized trial of TMVr plus guideline-directed medical therapy (GDMT) versus GDMT alone. Patients on corticosteroids or continuous oxygen were excluded. Multivariable models were used to examine the associations of COPD with mortality, heart failure hospitalization (HFH), and health status and to test whether COPD modified the benefit of TMVr compared with GDMT. RESULTS: Among 614 patients, 143 (23.2%) had COPD. Among patients treated with TMVr, unadjusted analyses demonstrated increased 2-year mortality in those with COPD (hazard ratio [HR]: 2.08; 95% confidence interval [CI]: 1.33 to 3.26), but this association was attenuated after risk adjustment (adjusted HR: 1.48; 95% CI: 0.87 to 2.52). Although TMVr led to reduced 2-year mortality among patients without COPD (adjusted HR: 0.47; 95% CI: 0.33 to 0.67), for patients with COPD, 2-year all-cause mortality was similar after TMVr versus GDMT alone (adjusted HR: 0.94; 95% CI: 0.54 to 1.65; p(int) = 0.04), findings that reflect offsetting effects on cardiovascular and noncardiovascular mortality. In contrast, TMVr reduced HFH (adjusted HR: 0.48 [95% CI: 0.28 to 0.83] vs. 0.46 [95% CI: 0.34 to 0.63]; p(int) = 0.89) and improved both generic and disease-specific health status to a similar extent compared with GDMT alone in patients with and without COPD (p(int) >0.30 for all scales). CONCLUSIONS: In the COAPT trial, COPD was associated with attenuation of the survival benefit of TMVr versus GDMT compared with patients without COPD. However, the benefits of TMVr on both HFH and health status were similar regardless of COPD. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079).