Michael J. Mack M.D.

Baber, U., M. E. Farkouh, Y. Arbel, P. Muntner, G. Dangas, M. J. Mack, T. H. Hamza, R. Mehran and V. Fuster (2016). “Comparative efficacy of coronary artery bypass surgery vs. Percutaneous coronary intervention in patients with diabetes and multivessel coronary artery disease with or without chronic kidney disease.” Eur Heart J: 2016 Aug [Epub ahead of print].

Full text of this article.

BACKGROUND: The optimal method of coronary revascularization among patients with diabetes mellitus (DM) and multivessel coronary artery disease (CAD) complicated by chronic kidney disease (CKD) remains unknown. PURPOSE: To examine the impact of coronary artery bypass surgery (CABG) vs. percutaneous coronary intervention (PCI) on cardiovascular outcomes in patients with diabetes with and without CKD. METHODS: We conducted an ‘as-treated’ subgroup analysis of the FREEDOM trial to examine the therapeutic efficacy of CABG vs. PCI among patients with DM stratified by the presence (n = 451) or absence (n = 1392) of CKD. We defined CKD as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2. Baseline characteristics and clinical outcomes were compared between PCI and CABG groups within each CKD stratum. The primary endpoint was the composite occurrence of all-cause death, stroke or myocardial infarction [major adverse cardiovascular and cerebrovascular events (MACCE)]. Event rates were estimated at 5 years using the Kaplan-Meier approach and hazard ratios (HRs) for CABG (vs. PCI) were generated using Cox regression. RESULTS: Patients with CKD (mean eGFR 47 mL/min/1.73m2) were older and more often female compared to those without renal impairment. Over a median follow-up of 3.8 years, the effect of CABG on MACCE was consistent among those with CKD (26.0% vs. 35.6%; HR [95% CI]: 0.73 [0.50-1.05]) and without CKD (16.2% vs. 23.6%; HR [95% CI)]: 0.76 [0.58-1.00]) with no evidence of interaction (pint = 0.83). Stroke rates were non-significantly higher with CABG whereas rates of MI and repeat revascularization were significantly reduced with CABG in both groups. CONCLUSIONS: Compared to PCI, the effects of CABG on long-term risks for MACCE observed in the FREEDOM trial are preserved among patients with mild to moderate CKD.

Arsalan, M., G. Filardo, W. K. Kim, J. J. Squiers, B. Pollock, C. Liebetrau, J. Blumenstein, J. Kempfert, A. Van Linden, A. Arsalan-Werner, C. Hamm, M. J. Mack, H. Moellmann and T. Walther (2016). “Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation.” Clin Res Cardiol: 2016 Aug [Epub ahead of print].

Full text of this article.

BACKGROUND: Inverse associations between Body Mass Index (BMI) and Body Surface Area (BSA) with mortality in patients after Transcatheter Aortic Valve Implantation (TAVI) have been reported. This “obesity paradox” is controversial, and it remains unclear which parameter, BMI or BSA, is of greater prognostic value. The aim of this study was to investigate the association of BMI and BSA on short- and mid-term outcomes after TAVI. METHODS AND RESULTS: This prospective, observational study consisted of 917 consecutive patients undergoing TAVI at our center from 2011 to 2014. The association between BMI/BSA and mortality (at 30 days and 1 year) was assessed using restricted cubic spline functions in propensity-adjusted (by Society of Thoracic Surgeons (STS) risk factors) logistic and Cox proportional models, respectively. The median age of the patients was 82.6 years, with a mean STS Predicted Risk of Mortality (STS-PROM) of 6.6 +/- 4.3 %. Throughout the study period (mean follow-up time was 297 days), 150 (16.4 %) patients died; 72 (7.9 %) patients died within 30 days of TAVI. After risk adjustment, the association between body constitution and 30-day mortality was not significant for either measure (BMI p = 0.25; BSA p = 0.32). However, BMI (p = 0.01), but not BSA (p = 0.13), was significantly associated with 1-year survival. There was no association between stroke, vascular complications, or length of stay with BMI or BSA. CONCLUSIONS: BMI was associated with survival at 1-year after TAVI. Despite the trend towards implementing BSA in risk score calculation, BMI may be more suitable for the assessment of TAVI patients.

Badhwar, V., V. H. Thourani, G. Ailawadi and M. Mack (2016). “Transcatheter mitral valve therapy: The event horizon.” J Thorac Cardiovasc Surg 152(2): 330-336.

Full text of this article.

Transcatheter aortic valve replacement has entered the clinical armamentarium mainstream of surgeons and interventional cardiologists in the management of high- and extreme-risk patients with aortic stenosis. Transcatheter mitral valve therapies are closely following suit. A flurry of global innovation, research, and clinical activity over the last 10 years have led to dynamic changes to the technologic landscape. With 1 device commercially approved, and several more in early feasibility studies in the United States with significant equity investments by major device manufacturers, the point of no return for this field of therapy finding its way into daily clinical practice is upon us. The current progress and future development of transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) are outlined.

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.

Full text of this article.

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.

Rodriguez, E., L. W. Nifong, J. Bonatti, R. Casula, V. Falk, T. A. Folliguet, B. B. Kiaii, M. J. Mack, T. Mihaljevic, J. M. Smith, R. M. Suri, J. E. Bavaria, T. E. MacGillivray and W. R. Chitwood, Jr. (2016). “Pathway for surgeons and programs to establish and maintain a successful robot-assisted adult cardiac surgery program.” J Thorac Cardiovasc Surg 152(1): 9-13.

Full text of this article.

Few education programs offer training in robotic-assisted cardiac surgery. This emerging field requires a new training paradigm, and we present a pathway and criteria to engage in robotic surgery.