Research Spotlight

Still, S., M. Mencio, E. Ontiveros, J. Burdick and S. G. Leeds (2018). “Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks.” Ann Thorac Cardiovasc Surg 24(4): 173-179.

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BACKGROUND: To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. METHODS: We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. RESULTS: In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. CONCLUSION: Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

Squiers, J. J. and J. M. DiMaio (2018). “Don’t change the guidelines yet, randomized data on surgical left atrial appendage closure is on the horizon.” J Thorac Cardiovasc Surg 156(3): 1081-1082.

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This meta-analysis demonstrates clear short-term benefits to surgical LAA closure. Ongoing RCTs will most likely determine the future of clinical practice. Atrial fibrillation (AF) remains the most common rhythm disorder of clinical significance and one of the leading causes of cardiogenic ischemic events. The most common anatomic source of thrombus in patients with AF is the left atrial appendage (LAA). Greater than 10% of patients undergoing cardiac surgery have been diagnosed with AF preoperatively, so surgeons have naturally had long-standing interest in LAA interventions that might reduce the risk of stroke. Unfortunately, the data currently available to support routine surgical LAA occlusion present a mixed picture, even to the most optimistic surgeon. Ando and colleagues are to be congratulated on their exhaustive systematic review of the literature to gather the best data on surgical LAA occlusion and to determine its short-term (30-day or in-hospital) effectiveness regarding prevention of mortality and stroke via meta-analysis. The authors identified 3 randomized controlled trials (RCTs) and 4 adjusted retrospective studies for inclusion, although only 3 studies (totaling 2464 patients) contributed to the mortality end point and 6 studies (3846 patients) contributed to the stroke end point because of limitations in data extraction from the original publications. The meta-analysis demonstrated that surgical LAA occlusion was associated with a reduction in mortality (odds ratio, 0.384; 95% confidence interval, 0.233-0.631) and stroke (odds ratio, 0.622; 95% confidence interval, 0.388-0.988), with further sub-analyses identifying a particularly strong benefit in patients with preoperative AF and possibly with those undergoing valve interventions as well. Should not such clear-cut results have the guideline writers running to their desks with pencils sharpened to draft an update regarding surgical LAA closure? Not so fast because, despite its many strengths, this analysis has several important limitations. (Excerpt from commentary on Masahiko Ando et al., Concomitant surgical closure of left atrial appendage: A systematic review and meta-analysis,The Journal of Thoracic and Cardiovascular Surgery, Volume 156, Issue 3, September 2018, Pages 1071-1080.)

Soape, M. P., R. S. Rahimi, C. W. Spak and J. F. Trotter (2018). “Case Report of a Rare Presentation of Isolated Cytomegalovirus Hepatitis After Renal Transplantation.” Prog Transplant 28(3): 296-298.

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Although CMV infection and disease are recognized complications of renal transplant, CMV hepatitis is distinctly uncommon. A recent study showed kidney transplant recipients receiving CMV prophylaxis, and CMV disease incidence was 19.2%. Thus, CMV disease was not surprising in this case, given the multiple risk factors. Thymoglobulin induction alone increased the risk of CMV infection by 4 times. With these risk factors, the transplanted kidney was uncharacteristically spared. Our case reemphasizes the significance for CMV prophylaxis, which was not optimized with our patient, and stopping valganciclovir certainly contributed to disease progression. Prophylaxis is defined as administration of antiviral agents at the onset of the transplantation. Our institutional protocol outlines the prophylactic use of valganciclovir in all liver and kidney transplantations. Another form of preventive CMV therapy is preemptive, which involves periodic monitoring of viremia to allow for prompt treatment. It has been shown that any form of preventive treatment for any CMV serology status has decreased CMV-associated mortality, all-cause mortality, and clinically important diseases due to opportunistic infections. To our knowledge, it has been 20 years since an isolated CMV hepatitis in renal transplantation was reported in the United States and none since the advent of current CMV prophylaxis regimens. In conclusion, this case illustrates the importance of CMV prophylaxis while presenting a rare case of isolated CMV hepatitis. (Excerpt from text, p. 298; no abstract available.)

Schiattarella, G. G., A. Sannino, G. Esposito and C. Perrino (2018). “Diagnostics and therapeutic implications of gut microbiota alterations in cardiometabolic diseases.” Trends Cardiovasc Med Aug 7. [Epub ahead of print].

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Alterations in gut microbiota composition and its metabolic activity are emerging as one of the most powerful determinants of cardiovascular disease. Although our knowledge of the precise molecular mechanisms by which gut microbiota influences cardiometabolic homeostasis is still limited, a growing body of knowledge has recently been uncovered about the potential modulation of microbiome for cardiovascular diagnostic and therapeutic aspects. The multitude of interactions between the microorganisms inhabiting the digestive tract and the host has been recognized crucial in the development and progression of atherosclerosis, obesity, diabetes and hypertension. Here, we summarize the role of gut microbiota in host physiology as well as in the pathophysiology of the most common cardio-metabolic disorders, discussing the potential therapeutic opportunities offered by interventions aimed at modifying microbiome composition and activity.

Paulson, A. S., L. M. Hess, A. M. Liepa, Z. L. Cui, K. M. Aguilar, J. Clark and W. Schelman (2018). “Ramucirumab for the treatment of patients with gastric or gastroesophageal junction cancer in community oncology practices.” Gastric Cancer 21(5): 831-844.

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BACKGROUND: Limited real-world research has investigated ramucirumab for the treatment of patients with gastric or gastroesophageal junction (GEJ) cancer. This study was designed to describe ramucirumab monotherapy or combination therapy use in a community oncology practice setting. METHODS: This was a retrospective observational cohort study to describe the treatment of adult patients with gastric or GEJ cancer who initiated ramucirumab treatment between 4/21/14 and 6/30/16 within the US Oncology Network. Kaplan-Meier method and Cox proportional hazards regression analyses were used to assess clinical outcomes. Multivariable logistic regression models were used to assess patient-level predictors of ramucirumab monotherapy or combination therapy. RESULTS: A total of 505 patients (mean age 64.4 years; 75.1% male) were included in the analysis; subgroups included: monotherapy (22.8%; n = 115), combination therapy (77.2%; n = 390). Monotherapy patients were significantly older (67.7 vs. 63.4 years; P = 0.0006), received ramucirumab approximately 3 months later after diagnosis (16.9 vs. 14.1 months; P = 0.0318) and more frequently initiated ramucirumab in the third or later lines of treatment (38.3 vs. 8.2%; P<0.0001) than patients receiving combination therapy. Median overall survival (OS) for monotherapy and combination therapy from the start of second-line therapy was 5.5 months (confidence interval [CI] 4.3, 7.8) and 7.4 months (CI 6.6, 8.8), respectively. CONCLUSIONS: The results showed that patients who received ramucirumab monotherapy started ramucirumab therapy later after diagnosis and were older than those who received ramucirumab in combination. Additionally, survival data suggest that outcomes observed in community oncology practices are similar to data from phase 3 clinical trials.