Research Spotlight

Posted May 15th 2019

Screening Colonoscopy Should Be Available to All.

James W. Fleshman M.D.

James W. Fleshman M.D.

Wells, K. and J. Fleshman (2019). “Screening Colonoscopy Should Be Available to All.” JAMA Surg Apr 17. [Epub ahead of print].

Full text of this article.

In a retrospective review of 16,000 patients in a systemwide experience of screening colonoscopy, Sarvepalli et al determined that the association of endoscopist specialty (surgeon or gastroenterologist) with adenoma detection rate was insignificant. This counters previously reported lower quality for colonoscopies and increased risk of missed adenomas and interval cancers by surgeons and confirms that colonoscopic quality indicators are adequately met by both gastroenterologists and nongastroenterologists. Sarvepalli et al do report differences between specialties not owing to random features of the endoscopists and other confounders, specifically, a decrement in the proximal sessile serrated adenoma (SSA) detection rate of 2.3% by surgeons vs 5.6% by gastroenterologists. The clinical significance of a 3.3% difference in the proximal SSA detection rate is questionable. Proximal SSAs arise via CpG island methylator phenotype pathway, with higher rates of methylation and carcinogenesis occurring in an age-dependent pattern. In a pathology series of 2416 SSAs, SSA-associated carcinoma was diagnosed at a mean age of 76 years vs 67 years among those with carcinoma arising in conventional adenomas. The SSAs do not progress as often or as quickly as conventional adenomas, accounting for their presence in the elderly cohort. In longitudinal computed tomographic colonographic assessment, 22% of SSAs progress vs 41% of conventional adenomas at an annual volumetric growth rate of 12.7% vs 36.4% in conventional adenomas (P = .03). The difference in median age between patients with SSA and SSA-associated carcinoma is 15 years vs a 5-year difference from tubular adenoma to conventional carcinoma, suggesting a 3-fold longer rate of progression to malignancy in SSA. Therefore, a second screening colonoscopy in 10 years would likely detect an early cancer or larger SSA. An SSA-harboring carcinoma represented only 1% of all specimens, which, if applied to the Sarvepalli et al study’s difference of 3.3%, translates into a miss rate of 3 SSA-associated carcinomas per 10 000 colonoscopies. In view of a slower progression of SSA to cancer in most cases, allowing a slightly higher miss rate in surveillance colonoscopy performed by nongastroenterologists might be acceptable. Eventual polypectomy, as less aggressive SSA lesions become larger, would be akin to the management of anal intraepithelial neoplasia III, where frequent observation of an affected mucosal field to remove visible lesions preserves the organ and effectively prevents progression to cancer. This study validates the surgeon in providing a high-quality screening and, more importantly, broadens the limited pool of clinicians to address low national screening rates. The question becomes whether well-trained nonspecialty clinicians with an acceptable adenoma detection rate could also provide screening. (Excerpt from text, p. e1; no abstract available.)


Posted May 15th 2019

The Effect of Obstructive Sleep Apnea on 3-Year Outcomes in Patients Who Underwent Orthotopic Heart Transplantation.

Shelley A. Hall M.D.

Shelley A. Hall M.D.

Afzal, A., K. M. Tecson, A. K. Jamil, J. Felius, P. S. Garcha, S. A. Hall and S. A. Carey (2019). “The Effect of Obstructive Sleep Apnea on 3-Year Outcomes in Patients Who Underwent Orthotopic Heart Transplantation.” Am J Cardiol Apr 10. [Epub ahead of print].

Full text of this article.

Despite the well-known association between obstructive sleep apnea (OSA) and cardiovascular disease, there is a paucity of data regarding OSA in orthotopic heart transplant (OHT) recipients and its effect on clinical outcomes. Hence, we sought to determine the association between OSA, as detected by polysomnography, and late graft dysfunction (LGD) after OHT. In this retrospective review of consecutive OHT recipients from 2012 to 2014 at our center, we examined LGD, i.e., graft failure >1 year after OHT, through competing risks analysis. Due to small sample size and event counts, as well as preliminary testing which revealed statistically similar demographics and outcomes, we pooled patients who had treated OSA with those who had no OSA. Of 146 patients, 29 (20%) had untreated OSA, i.e., OSA without use of continuous positive airway pressure therapy, at the time of transplantation. Patients with untreated OSA were significantly older, heavier, and more likely to have baseline hypertension than those with treated/no OSA. Although there were no differences between groups in regard to short-term complications of acute kidney injury, cardiac allograft vasculopathy, or primary graft dysfunction, there were significant differences in the occurrence of LGD. Those with untreated OSA were at 3 times the risk of developing LGD than those with treated/no OSA (hazard ratio 3.2; 95% confidence interval 1.3 to 7.9; p=0.01). Because OSA is a common co-morbidity of OHT patients and because patients with untreated OSA have an elevated risk of LGD, screening for and treating OSA should occur during the OHT selection period.


Posted May 15th 2019

Proceedings of the Editorial Board Meeting of The American Journal of Cardiology on March 17, 2019, in New Orleans, Louisiana.

William C. Roberts M.D.

William C. Roberts M.D.

Roberts, W. C. (2019). “Proceedings of the Editorial Board Meeting of The American Journal of Cardiology on March 17, 2019, in New Orleans, Louisiana.” Am J Cardiol Apr 18. [Epub ahead of print].

Full text of this article.

The year 2018 was a good one for the American Journal of Cardiology. The number of manuscripts submitted in 2018 increased 3.4% from the previous year (3,360 → 3,479), an average of 67 per week of which an average of 12 were accepted each week. The acceptance rate decreased from 19% in 2017 to 18% in 2018. The acceptance rate has continued to decrease during the present editorship even though the AJC publishes more manuscripts each year than any other cardiology journal in the world. A total of 573 articles were published in the AJC in 2018, a decrease from 700 published in 2017. This number excludes Readers’ Comments (Letters to the Editor). There is no limitation in the total number of tables and figures in articles published in the AJC, in contrast to the limitations (usually 8) of most cardiology journals. As a consequence, the AJC publishes more figures and tables than other major cardiovascular journals. The average length of the text of articles published in the AJC is almost certainly less than in other cardiology journals. The publisher of the AJC in 2018 provided a total of 3,891 editorial pages, of which 3735 (96%) were used for publishing articles and 42 for publishing Readers’ Comments. Total circulation of the AJC in 2018, according to the publisher, was just over 23,000. (Excerpt from text of article-in-press, p. 2; no abstract available.)


Posted May 15th 2019

Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.

Paul A. Grayburn M.D.

Paul A. Grayburn M.D.

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol 123(8): 1314-1320.

Full text of this article.

This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.


Posted May 15th 2019

Usefulness of Atherectomy in Chronic Total Occlusion Interventions (from the PROGRESS-CTO Registry).

James W. Choi M.D.

James W. Choi M.D.

Xenogiannis, I., D. Karmpaliotis, K. Alaswad, F. A. Jaffer, R. W. Yeh, M. Patel, E. Mahmud, J. W. Choi, M. N. Burke, A. H. Doing, P. Dattilo, C. Toma, A. J. C. Smith, B. Uretsky, O. Krestyaninov, D. Khelimskii, E. Holper, S. Potluri . . . and E. S. Brilakis (2019). “Usefulness of Atherectomy in Chronic Total Occlusion Interventions (from the PROGRESS-CTO Registry).” Am J Cardiol 123(9): 1422-1428.

Full text of this article.

There is limited data on the use of atherectomy during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We compared the clinical and procedural characteristics and outcomes of CTO PCIs performed with or without atherectomy in a contemporary multicenter CTO PCI registry. Between 2012 and 2018, 3,607 CTO PCIs were performed at 21 participating centers. Atherectomy was used in 117 (3.2%) cases: rotational atherectomy in 105 cases, orbital atherectomy in 8, and both in 4 cases. Patients in whom atherectomy was used, were older (68 +/- 8 vs 64 +/- 10 years, p <0.0001) and had higher Japan-chronic total occlusion score (3.0 +/- 1.2 vs 2.4 +/- 1.3, p <0.0001). CTO PCI cases in which atherectomy was used had similar technical (91% vs 87%, p=0.240) and procedural (90% vs 85%, p=0.159) success and in-hospital major adverse cardiac event (4% vs 3%, p=0.382) rates. However, atherectomy cases were associated with higher rates of donor vessel injury (4% vs 1%, p=0.031), tamponade requiring pericardiocentesis (2.6% vs 0.4%, p=0.012) and more often required use of a left ventricular assist device (9% vs 5%, p=0.031). Atherectomy cases were associated with longer procedural duration (196 [141, 247] vs 119 [76, 180] minutes, p <0.0001), and higher patient air kerma radiation dose (3.6 [2.5, 5.6] vs 2.8 [1.6, 4.7] Gray, p=0.001). In conclusion, atherectomy is currently performed in approximately 3% of CTO PCI cases and is associated with similar technical and procedural success and overall major adverse cardiac event rates, but higher risk for donor vessel injury and tamponade.