Cardiology

Aggarwal, M., Ros, E., Allen, K., Sikand, G., Agarwala, A., Aspry, K., Kris-Etherton, P., Devries, S., Reddy, K., Singh, T., Litwin, S. E., Keefe, J. O., Miller, M., Andrus, B., Blankstein, R., Batiste, C., Belardo, D., Wenger, C., Batts, T., Barnard, N. D., White, B. A., Ornish, D., Williams, K. A., Ostfeld, R. J. and Freeman, A. M. (2022).
“Controversial Dietary Patterns: A High Yield Primer for Clinicians.” Am J Med.

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In cardiology clinic visits, the discussion of optimal dietary patterns for prevention and management of cardiovascular disease is usually very limited. Herein, we explore the benefits and risks of various dietary patterns including intermittent fasting (IF), low carbohydrate, Paleolithic, whole food plant based diet and Mediterranean dietary patterns within the context of cardiovascular disease to empower clinicians with the evidence and information they need to maximally benefit their patients.

Squiers, J.J., DiMaio, J.M., Schaffer, J.M., Baxter, R.D., Gable, C.E., Shinn, K.V., Harrington, K., Moore, D.O., Shutze, W.P., Brinkman, W.T. and Gable, D.R. (2022). “Surgical Debranching versus Branched Endografting in Zone 2 Thoracic Endovascular Aortic Repair.” J Vasc Surg Jan 5;S0741-5214(21)02748-8. [Epub ahead of print].

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INTRODUCTION: Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with proximal zone 2 landing requiring coverage of the LSA. The gold-standard remains surgical LSA revascularization, but recently the feasibility of branched endografts has been demonstrated. We compared the perioperative and mid-term outcomes of these approaches. METHODS: A retrospective review of consecutive patients undergoing TEVAR with proximal zone 2 landing at a single center from 2014-2020 was performed. Patients were divided into cohorts for comparison: those undergoing surgical revascularization (SR-TEVAR group) and those undergoing thoracic branched endografting with an investigational device (TBE group). Patients who did not receive LSA revascularization were excluded. Perioperative outcomes including procedural success, death, stroke, limb ischemia, and length of stay were compared. Kaplan-Meier survival curves were compared with the log-rank test. The cumulative incidences of device-related endoleak (type I and III) and device-related reintervention, accounting for death as a competing hazard, were compared with the Fine-Gray test. RESULTS: A total of 55 patients were included: 31 (56%) SR-TEVAR and 24 (44%) TBE. Preoperative demographics and comorbidities were similar between the groups. Procedural success was 100% in both cohorts, and there were no periprocedural strokes or left upper extremity ischemic events. One operative/30-day mortality (TBE 4.2% vs SR-TEVAR 3.2%, p=0.99) occurred in each cohort. Total operative time (minutes, TBE 203 ± 79 vs SR-TEVAR 250 ± 79 p=0.03) and total length of stay (days, TBE 5.2 ± 3.6 vs SR-TEVAR 9.9 ± 7.2, p=0.004) were both significantly shorter in the TBE group. There was no difference in mid-term survival (log-rank p=0.50), nor the cumulative incidence of device-related endoleak (Fine-Gray p=0.51) or reintervention (Fine-Gray p=0.72). There have been no occlusions of the TBE graft nor surgical bypass/transpositions after a mean follow-up for 28 ± 16 and 34 ± 24 months, respectively. CONCLUSIONS: Thoracic branched endografting can be performed with similar procedural success and comparable safety profile to TEVAR with surgical revascularization, while reducing total length of stay, in patients requiring proximal zone 2 coverage. Mid-term outcomes of each approach are also similar. Prospective, randomized comparisons of these techniques are warranted.

Squiers, J.J., Thatcher, J.E., Bastawros, D.S., Applewhite, A.J., Baxter, R.D., Yi, F., Quan, P., Yu, S., DiMaio, J.M. and Gable, D.R. (2022). “Machine learning analysis of multispectral imaging and clinical risk factors to predict amputation wound healing.” J Vasc Surg 75(1): 279-285.

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OBJECTIVE: Prediction of amputation wound healing is challenging due to the multifactorial nature of critical limb ischemia and lack of objective assessment tools. Up to one-third of amputations require revision to a more proximal level within 1 year. We tested a novel wound imaging system to predict amputation wound healing at initial evaluation. METHODS: Patients planned to undergo amputation due to critical limb ischemia were prospectively enrolled. Clinicians evaluated the patients in traditional fashion, and all clinical decisions for amputation level were determined by the clinician’s judgement. Multispectral images of the lower extremity were obtained preoperatively using a novel wound imaging system. Clinicians were blinded to the machine analysis. A standardized wound healing assessment was performed on postoperative day 30 by physical exam to determine whether the amputation site achieved complete healing. If operative revision or higher level of amputation was required, this was undertaken based solely upon the provider’s clinical judgement. A machine learning algorithm combining the multispectral imaging data with patient clinical risk factors was trained and tested using cross-validation to measure the wound imaging system’s accuracy of predicting amputation wound healing. RESULTS: A total of 22 patients undergoing 25 amputations (10 toe, five transmetatarsal, eight below-knee, and two above-knee amputations) were enrolled. Eleven amputations (44%) were non-healing after 30 days. The machine learning algorithm had 91% sensitivity and 86% specificity for prediction of non-healing amputation sites (area under curve, 0.89). CONCLUSIONS: This pilot study suggests that a machine learning algorithm combining multispectral wound imaging with patient clinical risk factors may improve prediction of amputation wound healing and therefore decrease the need for reoperation and incidence of delayed healing. We propose that this, in turn, may offer significant cost savings to the patient and health system in addition to decreasing length of stay for patients.

Roberts, W.C., Salam, Y.M. and Roberts, C.S. (2022). “Morphologic Findings in Native Mitral Valves Replaced for Isolated Acute Infective Endocarditis.” Am J Cardiol 162: 136-142.

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Described here are some clinical and morphological observations in 37 adults having mitral valve replacement for active infective endocarditis limited to the mitral valve. The operatively-excised mitral valves are illustrated in 11 of the 37 patients, and photographs in them show that mitral valve repair in them would have been fruitless. Of the 37 patients, 32 (86%) survived the early operative period (30 days) and 31 (84%) were alive one year after the mitral operation. Of the 37 patients, 34 (92%) appeared to have had anatomically normal mitral valves before the infective endocarditis appeared.

Roberts, C.S. (2022). “The Physician Legacy of Stewart R. Roberts, MD (1878-1941), “The Osler of the South”.” Am J Cardiol 162: 191-196.

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A comparison of Stewart R. Roberts, MD, to the great Sir William Osler (1849–1919) is not the purpose or argument of this article. Virtually no one compares to Osler, who was considered the greatest physician of his generation in the English-speaking world. His single-authored medical textbook of 1892 was a tremendous achievement.² The career path of Osler, from Montreal to Philadelphia to Baltimore, and finally to Oxford, England, never crossed that of Roberts, who was born a generation later and spent his entire medical career in the South, peculiar in its agrarian tradition and racial demography and, by far, the most economically depressed region in the United States for decades after the Civil War. [No abstract; excerpt from article].