Research Spotlight

Posted July 15th 2016

Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of Society of Cardiovascular Angiography and Intervention (SCAI) cardiologists.

Peter McCullough M.D.

Peter McCullough M.D.

Prasad, A., A. Sohn, J. Morales, K. Williams, S. R. Bailey, D. Levin, P. A. McCullough, R. Mehran, G. Lopez-Cruz and J. Harder (2016). “Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of society of cardiovascular angiography and intervention (scai) cardiologists.” Catheter Cardiovasc Interv: 2016 June [Epub ahead of print].

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OBJECTIVES: The goal of the present study was to survey the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists to evaluate contemporary practice patterns with regards to contrast use, acute kidney injury (AKI) risk assessment, and prevention in patients undergoing invasive angiography. We sought to compare the physician responses against guideline statements and evidence-based data from clinical studies. METHODS: A 20-question online survey based on a modified Likert scale was sent out via email to the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists. The survey questions focused on prophylaxis methods, medication management, risk assessment, contrast agent use, and postprocedure care. A scoring system was developed which examined the individual responses to analyze the 10 questions with the greatest strength of evidence in the literature and guidelines. RESULTS: The survey was completed by 506 individuals. Selected responses of note included the use of standardized volume expansion protocols: 64.8%, use of iso-osmolar contrast (iodixanol) in the majority of patients at risk of AKI: 55%, and 27% of individuals reported diluting contrast with saline for patients at risk of AKI during coronary angiography. For questions with support from guideline documents, 56.9% of the responses were scored as concordant with evidence-based data. Individuals who reported that the risk of AKI was often or always important in planning angiography for “at risk patients” were more likely to closely monitor renal function (76.7% vs. 40.0%, P = 0.003), obtain nephrology consultation (45.2% vs. 13.3%, P = 0.016) and use iso-osmolar contrast agents (56.0% vs. 26.7%, P = 0.033). CONCLUSIONS: The majority of cardiologists participating in this survey, reported practice patterns consistent with guideline and evidence-based recommendations. However, over 40% of responses to questions were inconsistent with these recommendations, suggesting continued opportunities for education and quality improvement concerning AKI prevention.


Posted July 15th 2016

The father of septal myectomy for obstructive HCM, who also had HCM: The unbelievable story.

William C. Roberts M.D.

William C. Roberts M.D.

Maron, B. J. and W. C. Roberts (2016). “The father of septal myectomy for obstructive HCM, who also had HCM: The unbelievable story.” J Am Coll Cardiol 67(24): 2900-2903.

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Andrew Glenn Morrow, MD, was Chief of the Clinic of Surgery at the National Institutes of Health (NIH), Bethesda, Maryland, from 1953 until his death in 1982 (Figure 1). During that time, he established an international training program for future cardiac surgeons, and among many other accomplishments, the ventricular septal myectomy operation for obstructive hypertrophic cardiomyopathy (HCM) 1 and 2.


Posted July 15th 2016

The impact of aneurysm morphology and anatomic characteristics on long-term survival after endovascular abdominal aortic aneurysm repair.

William P. Shutze M.D.

William P. Shutze M.D.

Mahajan, A., M. Barber, T. Cumbie, G. Filardo, W. P. Shutze, Jr., D. M. Sass and W. Shutze, Sr. (2016). “The impact of aneurysm morphology and anatomic characteristics on long-term survival after endovascular abdominal aortic aneurysm repair.” Ann Vasc Surg 34: 75-83.

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BACKGROUND: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and the placement of endografts not in concordance with the specific device anatomic guidelines (or instructions for use [IFU]) have shown decreased technical success of the procedure. But these factors have never been evaluated in regard to patient postoperative survival. We sought to assess the association between survival and (1) aneurysm anatomy and characteristics and (2) implantation in compliance with manufacturer’s anatomic IFU guidelines in patients undergoing endovascular aortic aneurysm repair. METHODS: The cohort included 273 consecutive patients who underwent EVAR at Baylor Heart and Vascular Hospital between January 1, 2002 and December 31, 2009 and had their preoperative computed tomography (CT) scan digitally retrievable. The CT scans and operative notes were then reviewed, and the anatomic severity grading (ASG) score, maximum aneurysm diameter, thrombus width, patency of aortic side branch vessels, and implantation in compliance with IFU guidelines were assessed. The unadjusted association between survival (assessed until November 1, 2011) and these variables was assessed with the Kaplan-Meier method. Moreover, propensity-adjusted (for a comprehensive array of clinical and nonclinical risk factors) proportional hazard models were developed to assess the adjusted associations. RESULTS: Seven (2.56%) patients died within 30 days from EVAR, and 88 (30.04%) patients died during the study follow-up. Patient mean survival was 6.3 years. The unadjusted analysis showed a statistically significant association between survival and thrombus width (P = 0.007), ASG score (P = 0.004), and implantation in compliance with IFU guidelines (P = 0.007). However, the adjusted analysis revealed that none of the anatomic and compliance factors were significantly associated with long-term survival (ASG, P = 0.149; diameter, P = 0.836; thrombus, P = 0.639; patency, P = 0.219; and implantation compliance, P = 0.219). CONCLUSIONS: Unfavorable aneurysm morphologic characteristics and endograft implantation not in compliance with IFU guidelines did not adversely affect patient survival after EVAR in this group of patients. This implies that unfavorable anatomy, even that which would necessitate implantation of the EVAR device outside of the IFU guidelines, should not necessarily contraindicate EVAR.


Posted July 15th 2016

Comparison of Characteristics of Patients Undergoing Heart Transplantation at the Same Hospital in Two Different Time Periods (1997-2012 and 2013-2015).

William C. Roberts M.D.

William C. Roberts M.D.

Roberts, W. C., V. S. Won, A. Vasudevan, P. Kapoor, J. M. Ko, D. M. Meyer, S. A. Hall and G. V. Gonzalez-Stawinski (2016). “Comparison of characteristics of patients undergoing heart transplantation at the same hospital in two different time periods (1997-2012 and 2013-2015).” Am J Cardiol 118(2): 288-291.

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Heart transplantation (HT) increases at some centers each year and decreases at others. We examined characteristics of patients having HT at the same hospital in 2 different time periods (1997-2012 and 2013-2015) by 2 different surgical groups. We compared certain clinical and morphological finding in 291 patients having HT 1997 to 2012 to finding in 228 other patients having HT from 2013 to 2015. Several significant (p <0.05) differences were found: in the most recent time period (2013-2015) compared to the earlier time period (1997-2012), the mean ages of the men were older (57 years -vs- 55 years); diabetes mellitus was more frequent (37% -vs- 21%); systemic hypertension (by history) was more frequent (59% -vs- 32%); the mean body mass index was higher (29.2 kg/m(2) -vs- 26.5 kg/m(2)), and mean heart weight was lower in both men (509 g -vs- 549 g) and women (422 g -vs- 454 g). There were insignificant (p >0.05) differences in gender, frequency of massive cardiac adiposity, underlying cardiac condition, frequency of coronary heart disease, and frequency of previous insertion of a left ventricular assist device. In conclusion, certain characteristics of patients having HT at one Texas hospital changed in several respects in 2 time periods corresponding to changes in surgeons doing the HTs.


Posted July 15th 2016

Rapid on-site evaluation in detection of granulomas in the mediastinal lymph nodes.

Haala Rokadia M.D.

Haala Rokadia M.D.

Rokadia, H. K., A. Mehta, D. A. Culver, J. Patel, M. Machuzak, F. Almeida, T. Gildea, S. Sethi, K. Zell and J. Cicenia (2016). “Rapid on-site evaluation in detection of granulomas in the mediastinal lymph nodes.” Ann Am Thorac Soc 13(6): 850-855.

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RATIONALE: Rapid On-Site Evaluation (ROSE) of specimens collected by endobronchial ultrasound (EBUS)-guided-transbronchial needle aspiration (TBNA) ensures sample adequacy and triages subsequent biopsy procedures. EBUS-TBNA allows sampling of lymph nodes in granulomatous diseases; however, the ability of ROSE to predict the final diagnosis in this setting has not been well characterized. OBJECTIVES: We performed a retrospective evaluation to study the utility of ROSE in the diagnosis of granulomatous diseases as well as to establish the procedure characteristics that would optimize the concordance between ROSE and final diagnosis. METHODS: Charts of patients with a cytological diagnosis of granuloma by EBUS-TBNA between June 2008 and May 2013 were reviewed. Preliminary ROSE findings and final cytological diagnosis were compared. Patient demographics and procedure variables were assessed using mean (+/-SD). The variables collected were considered in a logistic regression analysis using concordance as the outcome. MEASUREMENTS AND MAIN RESULTS: In our study, 255 procedures were performed to sample 625 lymph nodes that contained granulomas. An average of 2.4 (+/-1.2) lymph nodes were biopsied per procedure, with a mean size of 14.4 (+/-7.9) mm. The concordance between ROSE and the final diagnosis was 81.6%. The concordance rate was not impacted by needle size, lymph nodes size or station, number of stations biopsied, or passes per lymph node. The concordance did improve with the experience of the bronchoscopist (P < 0001). CONCLUSIONS: In this single-center study, there was a high concordance between ROSE and the final cytological diagnosis for mediastinal lymph nodes containing granulomas that were sampled by EBUS-TBNA. ROSE may serve to reduce procedure time, enhance sample triaging, and obviate the need for further invasive testing. The only variable associated with increased concordance was the experience of the operator.