Does Gender Bias Play A Role in Cardiovascular Surgery in Women?

MedicalResearch.com Interview with:

Habib Jabagi B.Sc., M.Sc., M.D. Department of Surgery University of Ottawa , Ottawa

Dr.  Jabagi

Habib Jabagi B.Sc., M.Sc., M.D.
Department of Surgery
University of Ottawa , Ottawa

MedicalResearch.com: What is the background for this study? What are the main findings

Response: Women with coronary artery disease (CAD) are at a significant disadvantage compared to men, as they do not consistently receive the same intensive treatment. For example, when surgery is done in men, it is more common to use arteries, as opposed to saphenous veins from the leg to complete the bypass graft. Arteries, such as the left internal thoracic artery, appear to have much better long-term patency than veins, which translates into improved outcomes.

The motivation for this study was to see if our centre, which has embraced the use of arteries quite aggressively, has suffered the same gender disparities with respect to the use of multiple arterial revascularization strategies in coronary artery bypass grafting (CABG).

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Metformin Associated With Lower Mortality in CKD, CHF and Chronic Liver Disease

MedicalResearch.com Interview with:

Matthew J. Crowley, MD, MHS Assistant Professor of Medicine Member in the Duke Clinical Research Institute Duke University Medical Center

Dr. Matthew Crowley

Matthew J. Crowley, MD, MHS
Assistant Professor of Medicine
Member in the Duke Clinical Research Institute
Duke University Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Although metformin is widely considered to be the first-line drug for type 2 diabetes, concerns about lactic acidosis have traditionally limited its use in some populations. However, FDA now indicates that metformin may be used safely for patients with mild-moderate chronic kidney disease and other historical contraindications like congestive heart failure. With the lactic acidosis question addressed for these groups, this review asked “what do we know about how metformin affects mortality and other outcomes for patients with historical contraindications and precautions?”

The main take-home message is that metformin appears associated with lower mortality in patients with mild-moderate chronic kidney disease, congestive heart failure, and chronic liver disease.

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Transfemoral TAVI More Beneficial than Surgery For Some With Aortic Stenosis

MedicalResearch.com Interview with:

Giovanni Esposito

Dr. Giovanni Esposito

Giovanni Esposito MD, PhD
Associate Professor of Cardiology
Department of Advanced Biomedical Sciences
Federico II University, Naples
Napoli – Italy and
Giuseppe Gargiulo, MD
PhD Student
Federico II University of Naples, Italy

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Esposito: Aortic stenosis (AS) is the most frequent type of valvular heart disease in Europe and North America. As soon as symptoms occur, the prognosis of severe AS is poor, with majority of patients dying within 2 to 5 years. Unfortunately medical therapy of AS has no significant effects on patient survival, therefore the only treatment able to improve patient prognosis is valve replacement. Until 2002, the only treatment strategy was the surgical aortic valve replacement (SAVR). SAVR requires an open-heart procedure and cannot be offered to all patients with AS due to their advanced age and presence of comorbidities that make them inoperable or at high-risk for surgery.

In the last decade, the less invasive percutaneous approach called transcatheter aortic valve implantation (TAVI) has demonstrated to be a valid alternative to SAVR for those patients deemed inoperable or at high risk for SAVR. After the first percutaneous intervention performed by Alain Cribier in 2002, TAVI has rapidly accumulated growing interest and enthusiasm that led to the first PARTNER trial guiding current guideline recommendations. Both American and European guidelines recommend to perform TAVI in all patients judged inoperable, and to consider TAVI as an alternative in high-risk patients, but with a Class IIb and a preference to SAVR. However, scientific evidence on TAVI exploded in the last few years, the guidelines cited are outdated (2014 and 2012 respectively), we have today 5 randomized trials and many other observational studies including patients with different pre-procedural risk (i.e lo-to-intermediate and high-risk), as well as long-term results of prior studies (i.e. 5-year follow-up of the PARTNER trial and 3-year of the US CoreValve trial), therefore we conducted a systematic review and meta-analysis comparing clinical outcomes, including short- and mid-term mortality, of adult patients with severe aortic stenosis undergoing either TAVI or SAVR with the aim to update this comparison and offer new perspectives.

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Better Aortic Valve Replacement Outcomes At High Volume Hospitals

Dr. Christian McNeely, MD Resident Physician, Division of Cardiothoracic Surgery Barnes-Jewish Hospital/Washington University Medical Center St. Louis, Missosuri

Dr. Christian McNeely

MedicalResearch.com Interview with:
Dr. Christian McNeely, MD
Resident Physician, Department of Medicine
Barnes-Jewish Hospital/Washington University Medical Center
St. Louis, Missosuri 

MedicalResearch: What is the background for this study? What are the main findings?

Dr. McNeely : Since year 2000, 30-day mortality of aortic valve replacement (AVR) in Medicare beneficiaries has improved. Additionally, mechanical valve use in the elderly, which are often avoided in older patients largely because the risk of bleeding complications outweighs the risk of valve deterioration over time, has fallen significantly. Prior research has demonstrated worse outcomes in cardiac surgery for lower volume centers. Therefore, we sought to investigate the longitudinal relationship between institutional volume and outcomes in AVR using the Medicare database, looking at patients only > 65 years over a 10-year period.

We found that, in general, mechanical valve use in the elderly decreased with increasing hospital volume. Lower volume hospitals exhibited increased adjusted operative mortality. Importantly, the discrepancy in operative mortality between low and high-volume hospitals diverged during the course of the study such that higher volume centers demonstrated significantly greater improvement over time compared to lower volume centers.
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Statins May Reduce Risk of Complications and Death After Cardiac Surgery

Islam Elgendy, MD Clinical Pharmacology, Cardiology University of Florida

Dr. Islam Elgendy

MedicalResearch.com Interview with:
Islam Elgendy, MD
Clinical Pharmacology, Cardiology
University of Florida

Medical Research: What is the background for this study? What are the main findings?

Dr. Elgendy: This study aimed to review the current evidence for the effect of statin therapy before and after bypass surgery on different outcomes. The evidence suggests that statins can help reduce cardiac complications, such as atrial fibrillation, following the surgery. Statin use also seemed to be associated with a reduced risk of death during and immediately after bypass surgery.

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LVAD Use in CHF Increases, In-Hospital Mortality Decreases

MedicalResearch.com Interview with:
Neeraj Shah, MD, MPH
Cardiology Fellow
Department of Cardiology
Lehigh Valley Health Network
Allentown, PA.

Medical Research: What is the background for this study? What are the main findings?

Dr. Shah:  Congestive heart failure (CHF) affects 5.8 million Americans, with prevalence as high as 10% in individuals aged 65 years or more. There are long wait times for heart transplants. Left ventricular assist devices (LVADs) have been shown to significantly improve outcomes in end stage CHF patients. In the current situation of limited donor hearts, the utilization of LVAD technology is likely to increase over time. Moreover, the LVAD technology has improved considerably over time. The first generation devices were bulky and pulsatile in nature and of limited durability, whereas the second and third generation devices are smaller, longer lasting and exhibit “continuous flow”. The United States Food and Drug Administration (FDA) approved continuous flow devices in 2008. Presently, continuous flow devices account for over 95% of LVAD implants. Our aim was to examine the trends in utilization, in-hospital mortality, procedure related complications and cost of care after LVAD implantation from 2005 to 2011, and to study any differences in the pulsatile flow era from 2005-2007, compared to continuous flow era from 2008-2011. We used the Nationwide Inpatient Sample (NIS), which the largest all-payer US national hospitalization database, for our study. We identified LVAD implants using International Classification of Disease, 9th edition (ICD-9) procedure code 37.66. NIS data showed that there were 2,038 LVAD implantations from 2005 to 2011. LVAD utilization increased from 127 procedures in 2005 to 506 procedures in 2011, with a sharp increase after the year 2008 (from 149 procedures in 2007 to 257 procedures in 2008). In-hospital mortality associated with LVAD implantation decreased considerably from 47.2% in 2005 to 12.7% in 2011 (p<0.001), with a sharp decline in mortality after the year 2008 (from 38.9% in 2007 to 19.5% in 2008). Average length of stay (LOS) decreased from 44 days in the pulsatile-flow era to 36 days in the continuous-flow era. Cost of hospitalization increased from $194,380 in 2005 to $234,808 in 2011 but remained steady from 2008 to 2011. There was a trend of increased incidence of major bleeding and thromboembolism and decreased incidence of infectious and iatrogenic cardiac complications in the continuous-flow era. Thus, there has been a considerable increase in utilization of LVADs and decline in in-hospital mortality and LOS after LVAD implantation. These changes strongly coincide with US FDA approval of continuous flow devices in 2008.

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Mortality After Lung Cancer Resection Steadily Decreasing

Carlos E. Bravo Iñiguez, M.D. Clinical Research Fellow in Thoracic Oncology Brigham and Women´s Hospital (BWH)/Harvard Medical School (HMS) Department of Surgery, Division of Thoracic Surgery Center for Surgery and Public Health Boston, MA, 02115

Dr. Bravo

MedicalResearch.com Interview with:
Carlos E. Bravo Iñiguez, M.D.
Clinical Research Fellow in Thoracic Oncology
Brigham and Women´s Hospital (BWH)/Harvard Medical School (HMS)
Department of Surgery, Division of Thoracic Surgery
Center for Surgery and Public Health
Boston, MA, 02115

Medical Research: What is the background for this study? What are the main findings?

Dr. Bravo: The National Lung Screening Trial (NLST) determined the ability of low-dose computed tomography (LDCT) scans to reduce Lung Cancer specific mortality by 20% in high-risk patients. This reduction was partly dependent on the low surgical mortality experienced at the major academic centers, centers that were pioneers in minimally invasive lobectomy techniques.

In December 2013, The United States Preventive services task force (USPTF) endorsed annual low-dose computed tomography screening for Americans between ages 55 to 80 years who have 30 pack-years of smoking history and have smoked within 15 years.

On April 30th, 2014 the Centers for Medicare and Medicaid Services expressed concerns and raised skepticism as to whether the benefit of implementing a Lung Cancer Screening Program for the Medicare population could be maintained nationwide.  Specifically, they doubted low mortality and morbidity rates achieved by the NLST in the elderly patients could be maintained throughout the United States and across a broad range of hospital settings.

Medical Research: What are the main findings? 

Dr. Bravo: Mortality after lung resection has been decreasing over the past five decades. We analyzed a nationally validated database intended to measure and improve quality of surgical care – The American College of Surgeons National Surgical Quality improvement Program (ACS-NSQIP)- in order to find this answer.

The Overall Mortality rate was 2.34%. This included academic and community hospitals. Further analysis showed a significant difference on this rate depending on surgical technique: 3.13% for those undergoing Open thoracotomy lobectomy and 1.19% for those who underwent minimally invasive video-assisted Thoracoscopic lobectomy. Morbidity rate was 19.9% consistent with other recent prospective clinical trials. 

Medical Research: What should clinicians and patients take away from your report?

Dr. Bravo: These results showed that current operative mortality is not limited to pioneering centers in minimally invasive surgery or large academic centers but has now pervaded centers participating in the ACS-NSQIP database. Briefly, 8% of US hospitals providing adult care participate in the database. They include a mixture of academic centers and community hospitals with 29% of participants defined as non teaching hospitals and 31% having fewer than 500 licensed beds.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Bravo: Prospective data collection in the context of the recently implemented lung cancer screening program will be necessary to further refine screening criteria and implementation strategies. Also, results of ongoing randomized trials on sublobar resections for Lung cancer can favorably impact the results of the screening program reducing even more the morbidity and mortality.

Citation:

Thirty-Day Mortality After Lobectomy in Elderly Patients Eligible for Lung Cancer Screening

Bravo Iñiguez, Carlos E. et al.
The Annals of Thoracic Surgery Published Online:October 22, 2015

Carlos E. Bravo Iñiguez, M.D. (2015). Mortality After Lung Cancer Resection Steadily Decreasing 

Distance From Hospital Linked To Worse 30-Day Cardiac Surgery Outcomes

Dr. Ansar Hassan MD PhD Department of Cardiac Surgery New Brunswick Heart Centre Saint John Regional Hospital Saint John, New BrunswicMedicalResearch.com Interview with:
Dr. Ansar Hassan MD PhD
Department of Cardiac Surgery
New Brunswick Heart Centre
Saint John Regional Hospital
Saint John, New Brunswick

Medical Research: What is the background for this study? What are the main findings?

Dr. Hassan: For years, geographic place of residence and one’s proximity to a tertiary care center has been identified as a predictor for access to care.   Little is known regarding the effect of geography on patient outcomes.   The purpose of this study was to explore the relationship between geography and in-hospital / 30-day outcomes among patients undergoing cardiac surgery.  What we found was that despite there being no relationship between geography and in-hospital outcomes, those who lived further away from hospital clearly had worse 30-day outcomes.

Medical Research: What should clinicians and patients take away from your report?

Dr. Hassan: While patients from a differing geographic places of residence appear to have similar in-hospital outcomes following cardiac surgery, their clinical courses following discharge from hospital differ considerably.   Clinicians and patients need to realize that where one lives is tremendously important as it relates to his or her health and that particular attention needs to be paid to cardiac surgery patients who live further away from their tertiary care center, especially within the first 30 days following surgery.

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Lung Cancer Diagnosis and Staging Takes Too Long In Real World Settings

MedicalResearch.com Interview with: Raymond Osarogiagbon MD, FACP Thoracic Oncology Research Group Baptist Cancer Center Memphis, Tennessee MedicalResearch.com Interview with:
Raymond Osarogiagbon MD, FACP
Thoracic Oncology Research Group
Baptist Cancer Center
Memphis, Tennessee

Medical Research: What is the background for this study? What are the main findings?

Dr. Osarogiagbon: Lung cancer care is complicated, but can be broken down into 5 steps: x-ray detection, biopsy, x-ray tests of cancer spread (the ‘stage’), biopsy of suspicious areas where cancer may have spread, and treatment.

Looking only at patients who had surgery for a suspected lung cancer, we worked backwards to see how their care went through the key steps and how long it took.

We found that patients often skip some of the crucial steps. For example, 22% did not have a staging PET/CT scan, 88% did not have an invasive staging test. Only 10% had the recommended combination of 3 staging tests leading up to surgery: a CT scan, PET/CT scan, and invasive staging test.

It took a month and a half to more than 6 months for the middle half of patients to go from first abnormal x-ray sign of possible lung cancer to surgery.

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NGAL is Promising Biomarker of Kidney Injury After Heart Surgery

MedicalResearch.com Interview with:
Professeur Sidney Chocron

Chef de Service Chirurgie Thoracique et Cardio-Vasculaire
CHU de Besançon – Hôpital Jean Minjoz
BESANCON Cedex

Medical Research: What is the background for this study? What are the main findings?

Prof. Chocron: Acute kidney injury (AKI) is one of the most frequent complications after cardiac surgery.There is a time delay between the onset of renal impairment and the resulting telltale increase in blood creatinine levels.

Recent studies have underlined the promising properties of Neutrophil Gelatinase-Associated Lipocalin (NGAL). NGAL values early after surgery could predict the duration and severity of Acute Kidney Injury. In addition, NGAL can independently predict deteriorating renal function and could therefore be useful even in the context of pre-existing renal failure.

We aimed to assess the predictive ability of plasma NGAL levels to identify deteriorations in renal function after cardiac surgery in patients with pre-existing renal failure.

Medical Research: What are the main findings?

Prof. Chocron: One hundred sixty six patients with pre-operative renal failure i.e pre-operative creatinine clearance ≤60 mL/min/1.73m2 according to the Cockcroft Gault formula, were included in the study.

The threshold NGAL values at 6 hours after operation, as determined by ROC curve analysis was 155 ng/mL with a sensitivity of 79% and a specificity of 58%.

By multivariate analysis at 6 hours, a history of hypertension (OR=3.2 [1.2 – 8.9]), occurrence of at least 1 post-operative complication (OR=4.5 [1.3 – 15]), and an NGAL value above 155 ng/mL (OR=7.1 [2.7 – 18]) were shown to be independent predictors of the occurrence of post-operative AKI.

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Elders Requiring Fewer Hospital Days After Aortic Valve Surgery

Karthik Murugiah MBBS Fellow in Cardiovascular Medicine Yale School of Medicine Center for Outcomes Research and Evaluation (CORE) New Haven, CT 06510MedicalResearch.com Interview with:
Karthik Murugiah MBBS

Fellow in Cardiovascular Medicine
Yale School of Medicine
Center for Outcomes Research and Evaluation (CORE)
New Haven, CT 06510

Medical Research: What is the background for this study? What are the main findings?

Response: Aortic valve disease is common among older people and frequently requires valve replacement. 1-year survival after open surgical aortic valve replacement is high (9 in 10 survive the year after surgery). Our study focuses on the experience of these survivors in terms of the need for hospitalization during the year after surgery.

Among patients >65 years of age enrolled in Medicare who underwent surgical replacement of their aortic valve and survived at least one year, 3 in 5 were free from hospitalization during that year. Both, the rates of hospitalization and the average total number of days spent in the hospital in the year following surgery have been decreasing all through the last decade (1999 to 2010).

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Follow Your Heart Program Reduced Hospital Readmissions Following Heart Surgery

Michael H. Hall, MD North Shore-LIJ Health SystemMedicalResearch.com Interview with:
Michael H. Hall, MD
North Shore-LIJ Health System

MedicalResearch: What are the key points of your research?

Dr. Hall: Our study was designed to improve care transition from the hospital to home after coronary bypass surgery. The innovative program (Follow Your Heart), implemented at one of our system hospitals, involves sending cardiac surgery nurse practitioners (NPs) who cared for the patients in the hospital to the homes of discharged patients for at least two visits in the first two weeks after discharge. Their goal is to provide continuity of care for patients that they know from the hospital setting and to provide robust medication management, coordinate community services, and be a communications hub for hospital and community providers (primary care, cardiology, and community nurse home visit services). The  nurse practitioners interact with community resources to ensure understanding and satisfaction of the patients’ needs prior to hand-off to those resources after two weeks. Our  nurse practitioners utilize encrypted smart phones to provide reports to all appropriate providers and can even send pictures of incisions to the surgeon when necessary.

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COPD: Using FEV6 to Identify More Affected Patients

Surya P Bhatt MD Assistant Professor Division of Pulmonary and Critical Care Medicine University of Alabama at BirminghamMedicalResearch.com Interview with:
Surya P Bhatt MD
Assistant Professor
Division of Pulmonary and Critical Care Medicine
University of Alabama at Birmingham

MedicalResearch.com: What are the main findings of the study?

Dr. Bhatt:  The forced vital capacity (FVC) maneuver is a difficult maneuver for many patients and the forced expiratory volume in the first 6 seconds (FEV6) has been shown to be a reliable substitute. We used imaging findings on computed tomography, COPD questionnaires and tests of exercise capacity to compare these two spirometric measures (FEV1/FVC and FEV/FEV6) in the diagnosis of airflow obstruction, and showed that FEV6 can be reliably substituted for FVC. Our findings suggest that using FEV6 may in fact identify more patients with disease than by using FVC.

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Should Dental Extractions Be Done Prior to Heart Surgery?

Dr. Kendra J. Grim Department of Anesthesiology Mayo Clinic, Rochester, MN 55905MedicalResearch.com Interview with:
Dr. Kendra J. Grim
Department of Anesthesiology
Mayo Clinic, Rochester, MN 55905


MedicalResearch.com
: What are the main findings of the study?

Dr. Grim: “The current guidelines say that if possible, treating the dental problems that patients have before heart surgery is best, to try to prevent both early and late heart infections. But the data is very unclear, because it’s very difficult to study. We found in our study that their risk of serious complications after having teeth removed may be higher than we thought. We were primarily looking at stroke, heart attack, renal failure and death. We found that actually the incidence of having one of those major morbidities was 8 percent.  Of that 8 percent, we had six patients, or 3 percent, of the total group who died between their dental surgery and scheduled heart surgery, so these patients never made it to their heart surgery. An additional 3 percent of patients died after heart surgery. “

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Heart Transplantation and Mechanical Circulatory Support – Factors Influencing Graft Survival

Simon Maltais MD PhD Vanderbilt University Medical Center Division of Cardiovascular Surgery 1215 21st Ave S, MCE 5th Flr Nashville, TN 37232-8808.MedicalResearch.com Interview with: Simon Maltais MD PhD
Vanderbilt University Medical Center
Division of Cardiovascular Surgery
1215 21st Ave S, MCE 5th Flr
Nashville, TN 37232-8808.


MedicalResearch.com: What did your study evaluate and why is this important?

Answer: We performed a rigorous, retrospective review of the Scientific Registry of Transplant Recipients (SRTR) data base to evaluate donor, recipient, and technical characteristics associated with graft survival in patients undergoing mechanical circulatory support (MCS) device explantation at the time of heart transplantation surgery.

Donor and recipient characteristics has been well described in the medical literature for routine heart transplantation, however these characteristics in patients who were supported with a long term MCS device at the time of heart transplant was not known.  Additionally, due to chronic donor heart shortages, an increasing number of patients with advanced heart failure are being bridged with MSC devices until a suitable donor heart can be obtained.

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COPD and Coronary Artery Bypass Surgery

MedicalResearch.com Interview with: Hossein Almassi, MD

Professor, Cardiothoracic Surgery
Medical College of Wisconsin and
Zablocki VA Medical Center
Milwaukee, Wi, 53226

MedicalResearch.com: What are the main findings of the study?

Answer: The main findings of this study were that off-pump coronary bypass grafting did not have a positive differential impact on outcome of patients with COPD as compared to the standard operation performed on cardiopulmonary bypass.
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