Research Spotlight

Posted December 15th 2019

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Electroencephalography.

Michael A.E. Ramsay M.D.
Michael A.E. Ramsay M.D.

Chan, M. T. V., T. L. Hedrick, T. D. Egan, P. S. Garcia, S. Koch, P. L. Purdon, M. A. Ramsay, T. E. Miller, M. D. McEvoy and T. J. Gan (2019). “American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Electroencephalography.” Anesth Analg Nov 18. [Epub ahead of print].

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Electroencephalographic (EEG) monitoring to indicate brain state during anesthesia has become widely available. It remains unclear whether EEG-guided anesthesia influences perioperative outcomes. The sixth Perioperative Quality Initiative (POQI-6) brought together an international team of multidisciplinary experts from anesthesiology, biomedical engineering, neurology, and surgery to review the current literature and to develop consensus recommendations on the utility of EEG monitoring during anesthesia. We retrieved a total of 1023 articles addressing the use of EEG monitoring during anesthesia and conducted meta-analyses from 15 trials to determine the effect of EEG-guided anesthesia on the rate of unintentional awareness, postoperative delirium, neurocognitive disorder, and long-term mortality after surgery. After considering current evidence, the working group recommends that EEG monitoring should be considered as part of the vital organ monitors to guide anesthetic management. In addition, we encourage anesthesiologists to be knowledgeable in basic EEG interpretation, such as raw waveform, spectrogram, and processed indices, when using these devices. Current evidence suggests that EEG-guided anesthesia reduces the rate of awareness during total intravenous anesthesia and has similar efficacy in preventing awareness as compared with end-tidal anesthetic gas monitoring. There is, however, insufficient evidence to recommend the use of EEG monitoring for preventing postoperative delirium, neurocognitive disorder, or postoperative mortality.


Posted December 15th 2019

Cost-Effectiveness of Transcatheter Mitral Valve Repair Versus Medical Therapy in Patients With Heart Failure and Secondary Mitral Regurgitation: Results From the COAPT Trial.

Michael J. Mack M.D.
Michael J. Mack M.D.

Baron, S. J., K. Wang, S. V. Arnold, E. A. Magnuson, B. Whisenant, A. Brieke, M. Rinaldi, A. W. Asgar, J. Lindenfeld, W. T. Abraham, M. J. Mack, G. W. Stone and D. J. Cohen (2019). “Cost-Effectiveness of Transcatheter Mitral Valve Repair Versus Medical Therapy in Patients With Heart Failure and Secondary Mitral Regurgitation: Results From the COAPT Trial.” Circulation 140(23): 1881-1891.

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BACKGROUND: The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) demonstrated that edge-to-edge transcatheter mitral valve repair (TMVr) with the MitraClip resulted in reduced mortality and heart failure hospitalizations and improved quality of life compared with maximally tolerated guideline-directed medical therapy (GDMT) in patients with heart failure and 3 to 4+ secondary mitral regurgitation. Whether TMVr is cost-effective compared with GDMT in this population is unknown. METHODS: We used data from the COAPT trial to perform a formal patient-level economic analysis of TMVr+GDMT versus GDMT alone for patients with heart failure and 3 to 4+ secondary mitral regurgitation from the perspective of the US healthcare system. Costs for the index TMVr hospitalization were assessed using a combination of resource-based accounting and hospital billing data (when available). Follow-up medical care costs were estimated on the basis of medical resource use collected during the COAPT trial. Health utilities were estimated for all patients at baseline and 1, 6, 12, and 24 months with the Short Form Six-Dimension Health Survey. RESULTS: Initial costs for the TMVr procedure and index hospitalization were $35 755 and $48 198, respectively. Although follow-up costs were significantly lower with TMVr compared with GDMT ($26 654 versus $38 345; P=0.018), cumulative 2-year costs remained higher with TMVr because of the upfront cost of the index procedure ($73 416 versus $38 345; P<0.001). When in-trial survival, health utilities, and costs were modeled over a lifetime horizon, TMVr was projected to increase life expectancy by 1.13 years and quality-adjusted life-years by 0.82 years at a cost of $45 648, yielding a lifetime incremental cost-effectiveness ratio of $40 361 per life-year gained and $55 600 per quality-adjusted life-year gained. CONCLUSIONS: For symptomatic patients with heart failure and 3 to 4+ secondary mitral regurgitation, TMVr increases life expectancy and quality-adjusted life expectancy compared with GDMT at an incremental cost per quality-adjusted life-year gained that represents acceptable economic value according to current US thresholds. Clinical Trial Registration Unique Identifier: NCT01626079


Posted December 15th 2019

Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.

Brad R. Grimsley, M.D.
Brad R. Grimsley, M.D.

Balceniuk, M. D., M. A. Hosn, R. S. Corn, T. DerDerian, B. R. Grimsley, P. Long, W. S. Moore, P. J. Rossi, H. J. Shakir, A. H. Siddiqui, D. P. Spadone, M. Waqas and M. C. Stoner (2019). “Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.” J Vasc Surg Nov 15. [Epub ahead of print].

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OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.


Posted December 15th 2019

Recurrent Arginine Substitutions in the ACTG2 Gene are the Primary Driver of Disease Burden and Severity in Visceral Myopathy.

Katerina Wells M.D.
Katerina Wells M.D.

Assia Batzir, N., P. Kishor Bhagwat, A. Larson, Z. Coban Akdemir, M. Baglaj, L. Bofferding, K. B. Bosanko, S. Bouassida, B. Callewaert, A. Cannon, Y. Enchautegui Colon, A. D. Garnica, M. H. Harr, S. Heck, A. C. Hurst, S. N. Jhangiani, B. Isidor, R. O. Littlejohn, P. Liu, P. Magoulas, H. Mar Fan, R. Marom, S. McLean, M. M. Nezarati, K. M. Nugent, M. B. Petersen, M. Linda Rocha, E. Roeder, R. Smigiel, I. Tully, J. Weisfeld-Adams, K. O. Wells, J. E. Posey, J. R. Lupski, A. L. Beaudet and M. F. Wangler (2019). “Recurrent Arginine Substitutions in the ACTG2 Gene are the Primary Driver of Disease Burden and Severity in Visceral Myopathy.” Hum Mutat Nov 26. [Epub ahead of print].

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Visceral myopathy with abnormal intestinal and bladder peristalsis includes a clinical spectrum with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS), and Chronic Intestinal Pseudo-Obstruction (CIPO). The vast majority of cases are caused by dominant variants in ACTG2; however, the overall genetic architecture of visceral myopathy has not been well-characterized. We ascertained 53 families, with visceral myopathy based on megacystis, functional bladder/gastrointestinal obstruction or microcolon. A combination of targeted ACTG2 sequencing and exome sequencing was used. We report a molecular diagnostic rate of 64% (34/53), of which 97% (33/34) is attributed to ACTG2. Strikingly, missense mutations in five conserved arginine residues involving CpG dinucleotides, accounted for 49% (26/53) of disease in the cohort. As a group, the ACTG2- negative cases had a more favorable clinical outcome and more restricted disease. Within the ACTG2-positive group, poor outcomes (characterized by total parenteral nutrition dependence, death or transplantation) were invariably due to one of the arginine missense alleles. Analysis of specific residues suggests a severity spectrum of p.Arg178 > p.Arg257 > p.Arg40 along with other less frequently reported sites p.Arg63 and p.Arg211. These results provide genotype-phenotype correlation for ACTG2-related disease and demonstrate the importance of arginine missense changes in visceral myopathy.


Posted December 15th 2019

Meeting Report: The Dallas consensus conference on liver transplantation for alcohol related hepatitis.

Sumeet K. Asrani M.D.
Sumeet K. Asrani M.D.

Asrani, S. K., J. Trotter, J. Lake, A. Ahmed, A. Bonagura, A. Cameron, A. DiMartini, S. Gonzalez, G. Im, P. Martin, P. Mathurin, J. Mellinger, J. P. Rice, V. H. Shah, N. Terrault, A. Wall, S. Winder and G. Klintmalm (2019). “Meeting Report: The Dallas consensus conference on liver transplantation for alcohol related hepatitis.” Liver Transpl Nov 19. [Epub ahead of print].

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Liver transplantation (LT) for alcohol related hepatitis (AH) remains controversial. We convened a consensus conference to examine various aspects of LT for AH. The goal was not to unequivocally endorse LT for AH; instead it was to propose recommendations for programs that perform or plan to perform LT for AH. Criteria were established to determine candidacy for LT in the setting of AH and included the following: (1) AH patients presenting for the first time with decompensated liver disease that are non-responders to medical therapy without severe medical or psychiatric comorbidities (2) A fixed period of abstinence prior to transplantation is not required (3) Assessment with a multidisciplinary psychosocial team including a social worker and a addiction specialist/mental health professional with addiction and transplantation expertise. Supporting factors include lack of repeated unsuccessful attempts at addiction rehabilitation, lack of other substance use/dependency, acceptance of diagnosis/insight with commitment of patient/family to sobriety and formalized agreement to adhere to total alcohol abstinence and counseling. LT should be avoided in AH patients that are likely to spontaneously recover. Short- and long-term survival comparable to other indications for LT must be achieved. There should not be further disparity in LT either by indication, geography, or other sociodemographic factors. Treatment of alcohol use disorders should be incorporated into pre and post-LT care. The restrictive and focused evaluation process described in the initial LT experience for AH worldwide may not endure as this indication gains wider acceptance at more LT programs. Transparency in selection process is crucial with collection of objective data to assess outcomes and minimize center variation in listing. Oversight of program adherence is important to harmonize listing practices and outcomes.