Research Spotlight

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.

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.

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.

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.

Laskey, H. L., N. Schomaker, K. W. Hung, S. K. Asrani, L. Jennings, T. L. Nydam, J. Gralla, A. Wiseman, H. R. Rosen and S. W. Biggins (2016). “Predicting renal recovery after liver transplant with severe pretransplant subacute kidney injury: The impact of warm ischemic time.” Liver Transpl: 2016 June [Epub ahead of print].

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Identification of which liver transplant (LT) candidates with severe kidney injury will have full recovery of renal function after liver transplant alone (LTA) is difficult. Avoiding unnecessary simultaneous liver-kidney (SLK) transplant can optimize use of scarce kidney grafts. Incorrect predictions of spontaneous renal recovery after LTA can lead to increased morbidity and mortality. We retrospectively analyzed all LTA patients at our institution from 2/2002-2/2013 (n=583) and identified a cohort with severe subacute renal injury (n=40) [creatinine <2mg/dL in the 14-89 days prior to LTA and not on renal replacement therapy yet >/= 2mg/dLwithin 14 days of LTA and/or on renal replacement therapy]. Of 40 LTA recipients, 26 (65%) had renal recovery and 14 (35%) did not. The median (IQR) warm ischemic time (WIT, in minutes) in recipients with and without renal recovery after LTA was 31 (24-46) and 39 (34-49), p=0.02, respectively. Adjusting for severity of subacute kidney injury with either AKIN or RIFLE criteria, increasing WIT was associated with lack of renal recovery [serum creatinine <2 mg/dL after LTA, not on renal replacement therapy], OR 1.08 (1.01-1.16, p=0.03) and OR 1.09 (1.01-1.17, p=0.02), respectively. For each minute of increased WIT, there was an 8% to 9% increase in the risk of lack of renal recovery after LTA. In a separate cohort of 98 LTA recipients with subacute kidney injury, we confirmed the association of WIT and lack of renal recovery, OR 1.04, p=0.04. CONCLUSION: In LT candidates with severe subacute renal injury, operative measures to minimize WIT may improve renal recovery potentially avoiding renal replacement therapy and the need for subsequent kidney transplant.