Research Spotlight

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.

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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.

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.

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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.

Lai, J. C., R. S. Rahimi, E. C. Verna, M. R. Kappus, M. A. Dunn, M. McAdams-DeMarco, C. E. Haugen, M. L. Volk, A. Duarte-Rojo, D. R. Ganger, J. G. O’Leary, J. L. Dodge, D. Ladner and D. L. Segev (2019). “Frailty Associated With Waitlist Mortality Independent of Ascites and Hepatic Encephalopathy in a Multicenter Study.” Gastroenterology 156(6): 1675-1682.

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BACKGROUND & AIMS: Frailty is associated with mortality in patients with cirrhosis. We measured frailty using 3 simple tests and calculated Liver Frailty Index (LFI) scores for patients at multiple ambulatory centers. We investigated associations between LFI scores, ascites, and hepatic encephalopathy (HE) and mortality. METHODS: Adults without hepatocellular carcinoma who were on the liver transplantation waitlist at 9 centers in the United States (N = 1044) were evaluated using the LFI; LFI scores of at least 4.5 indicated that patients were frail. We performed logistic regression analyses to assess associations between frailty and ascites or HE and competing risk regression analyses (with liver transplantation as the competing risk) to estimate sub-hazard ratios (sHRs) of waitlist mortality (death or removal from the waitlist). RESULTS: Of study subjects, 36% had ascites, 41% had HE, and 25% were frail. The odds of frailty were higher for patients with ascites (adjusted odd ratio 1.56, 95% confidence interval [CI] 1.15-2.14) or HE (odd ratio 2.45, 95% CI 1.80-3.33) than for those without these features. Larger proportions of frail patients with ascites (29%) or HE (30%) died while on the waitlist compared with patients who were not frail (17% of patients with ascites and 20% with HE). In univariable analysis, ascites (sHR 1.52, 95% CI 1.14-2.05), HE (sHR 1.84, 95% CI 1.38-2.45), and frailty (sHR 2.38, 95% CI 1.77-3.20) were associated with waitlist mortality. In adjusted models, only frailty remained significantly associated with waitlist mortality (sHR 1.82, 95% CI 1.31-2.52); ascites and HE were not. CONCLUSIONS: Frailty is a prevalent complication of cirrhosis that is observed more frequently in patients with ascites or HE and independently associated with waitlist mortality. LFI scores can be used to objectively quantify risk of death related to frailty-in excess of liver disease severity-in patients with cirrhosis.

Mageto, Y. (2019). “The Increasing Use of Social Media for Medical Information: Should Healthcare Providers Be Concerned?” Ann Am Thorac Soc 16(5): 544-546.

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During the last decade, social media use among adults in the United States has increased exponentially. Intuitively, we might assume that the increase in use primarily involves Gen Xers (born 1965–1980) and younger generations. However, Traditionalists (born 1900–1945) and Baby Boomers (born 1946–1964) have also been noted to have a significant uptick in their use of social media. Usage has increased from 2% in 2005 to 25% in 2015. Many members of this generation have become increasingly savvy with their smartphones, using them to record conversations in physician’s offices as well as looking up information on the Internet. The most commonly used platforms are Facebook, Google, and YouTube. These same generations (Traditionalists and Baby Boomers) have increasingly turned to the Internet, accessing websites, viewing videos, and discussing their medical information online with other patients, caregivers, and anyone else who desires to chime in. YouTube and other web media platforms were never designed as a platform for medical research or medical education, but by default, they have become a platform for reporting/sharing research, medical education, and patient support. This invites the question: Why should we be concerned about what is posted on YouTube? If one simply views it as an entertainment platform, then it should not be an issue. But because it has become a platform for healthcare, it is past time to have additional discussions/research going forward, developing tools to assess content and use of said content, and holding those who post inaccurate and harmful information accountable. (Excerpt from text, p. 544; no abstract available.)

Snyder, R. J., J. Jensen, A. J. Applewhite, K. Couch, W. S. Joseph, J. C. Lantis Ii and T. E. Serena (2019). “A Standardized Approach to Evaluating Lower Extremity Chronic Wounds Using a Checklist.” Wounds 31(5 Suppl): S29-s44.

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As the population ages and more people live with diabetes, obesity, and vascular disease, chronic wounds have become more prevalent. Increasingly, wound care falls into the hands of clinicians who may be new to the specialty. To facilitate a better understanding of wounds and to ensure all integral items for best outcomes are considered, an interprofessional panel of wound care experts developed a checklist to aid in lower extremity wound identification, assessment, evaluation, and potential complication recognition. This checklist focuses on an evidence-based approach to obtaining a medical history, evaluating the wound, determining the etiology, and assessing perfusion, edema, infection, and neurologic status. The goal of this fundamental evaluation tool is to help the clinician move towards the next steps in optimizing patient care. Evidence-based support for each item on the checklist is reviewed and detailed for clinician reference.