Michael J. Mack M.D.

Gaudino, M., M. J. Mack and D. P. Taggart (2018). “Additional Arterial Conduits in Coronary Artery Bypass Surgery: Finally Coming of Age.” J Am Coll Cardiol 71(25): 2974-2976.

Full text of this article.

In April 1968, Rene Favaloro published his first description of the coronary artery bypass graft (CABG) surgery. In the 50 years since then, CABG has been arguably the most intensively studied surgical procedure. One of the most important and persistent controversies has been the ideal choice of conduits for revascularization, and in particular, whether the use of multiple arterial grafts leads to significantly improved long-term outcomes. Over the past 5 decades, a substantial amount of observational data reporting the beneficial effects of multiple arterial grafts has been published. The overwhelming majority of series reported a survival advantage, using predominantly either internal thoracic or radial arteries. Notably, even with propensity matching, these studies were almost exclusively based on retrospective observational data, and until < 2 years ago, no adequately powered, comparative, randomized trial had been published. The better outcomes associated with arterial grafts are hypothesized to result from their superior angiographic patency. Randomized trials and a network meta-analysis have consistently shown arterial conduits to have better mid- and long-term patency rates than saphenous vein grafts, providing a likely mechanistic explanation of the improved outcomes associated with the use of arteries. (Excerpt from this editorial; no abstract available.)

Gaudino, M., M. J. Mack and D. P. Taggart (2018). “Additional arterial conduits in coronary artery bypass surgery: Finally coming of age.” J Thorac Cardiovasc Surg Jun 8. [Epub ahead of print].

Full text of this article.

In April 1968, Rene Favaloro published his first description of the coronary artery bypass graft (CABG) surgery. In the 50 years since then, CABG has been arguably the most intensively studied surgical procedure. One of the most important and persistent controversies has been the ideal choice of conduits for revascularization, and in particular, whether the use of multiple arterial grafts leads to significantly improved long-term outcomes. Over the past 5 decades, a substantial amount of observational data reporting the beneficial effects of multiple arterial grafts has been published. The overwhelming majority of series reported a survival advantage, using predominantly either internal thoracic or radial arteries. Notably, even with propensity matching, these studies were almost exclusively based on retrospective observational data, and until < 2 years ago, no adequately powered, comparative, randomized trial had been published. The better outcomes associated with arterial grafts are hypothesized to result from their superior angiographic patency. Randomized trials and a network meta-analysis have consistently shown arterial conduits to have better mid- and long-term patency rates than saphenous vein grafts, providing a likely mechanistic explanation of the improved outcomes associated with the use of arteries. (Excerpt from this editorial; no abstract available.)

Mack, M. J., A. Vasudevan and M. Hamandi (2018). “TAVR in younger patients with aortic stenosis: anything new?” EuroIntervention 14(1): 29-30.

Full text of this article.

Transcatheter aortic valve replacement (TAVR) has been shown to be non-inferior to surgical aortic valve replacement (SAVR) in multiple randomised trials in high- and intermediate-risk patients. Most patients studied in these randomised trials were elderly, being for the most part in their late seventies and early eighties in age. Two trials in lower-risk patients which have recently completed enrolment in the USA presumably include younger patients. However, the results of those trials will not be available until mid 2019. In this issue of EuroIntervention, Eggebrecht and colleagues have attempted to shed some light on the outcomes of TAVR compared with SAVR in younger patients prior to the availability of those trial reports . . . In summary, there is little if any new information obtained in this study that helps to inform clinical practice. The cardiology and cardiac surgery community would be better off waiting for the outcomes of randomised trials in lower-risk and presumably younger patients before changing current practice in younger patients. Despite the efforts of the study investigators, there is nothing new here to inform the clinician. (Excerpts from text, p. 29-30; no abstract available.)

Mack, M., M. Hamandi and A. Gopal (2018). “TAC for TAVR: What Is the Score?” JACC Cardiovasc Imaging. May 11. [Epub ahead of print].

Full text of this article.

Commentary on Development of a Risk Score Based on Aortic Calcification to Predict 1-year Mortality After Transcatheter Aortic Valve Replacement, Pierre Lantelme M.D., Ph.D., JACC: Cardiovascular Imaging, published online 16 May 2018.

Lansky, A. J., S. R. Messe, A. M. Brickman, M. Dwyer, H. Bart van der Worp, R. M. Lazar, C. G. Pietras, K. J. Abrams, E. McFadden, N. H. Petersen, J. Browndyke, B. Prendergast, V. G. Ng, D. E. Cutlip, S. Kapadia, M. W. Krucoff, A. Linke, C. Scala Moy, J. Schofer, G. A. van Es, R. Virmani, J. Popma, M. K. Parides, S. Kodali, M. Bilello, R. Zivadinov, J. Akar, K. L. Furie, D. Gress, S. Voros, J. Moses, D. Greer, J. K. Forrest, D. Holmes, A. P. Kappetein, M. Mack and A. Baumbach (2018). “Proposed Standardized Neurological Endpoints for Cardiovascular Clinical Trials: An Academic Research Consortium Initiative.” Eur Heart J 39(19): 1687-1697.

Full text of this article.

Surgical and catheter-based cardiovascular procedures and adjunctive pharmacology have an inherent risk of neurological complications. The current diversity of neurological endpoint definitions and ascertainment methods in clinical trials has led to uncertainties in the neurological risk attributable to cardiovascular procedures and inconsistent evaluation of therapies intended to prevent or mitigate neurological injury. Benefit-risk assessment of such procedures should be on the basis of an evaluation of well-defined neurological outcomes that are ascertained with consistent methods and capture the full spectrum of neurovascular injury and its clinical effect. The Neurologic Academic Research Consortium is an international collaboration intended to establish consensus on the definition, classification, and assessment of neurological endpoints applicable to clinical trials of a broad range of cardiovascular interventions. Systematic application of the proposed definitions and assessments will improve our ability to evaluate the risks of cardiovascular procedures and the safety and effectiveness of preventive therapies.