New research was recently presented at ACC.12, the annual scientific meeting of the American College of Cardiology, from March 24-27 in Chicago. The features below highlight just some of the studies that emerged from the meeting that pertain specifically to the surgeon audience.
>> Positive Outcomes Observed With TAVI
>> Assessing the Safety of On- & Off-Pump CABG
>> TAVR Comparable to Open-Heart Surgery at 2 Years
>> Bariatric Surgery Yields Big Rewards for Obese Diabetics
>> Underweight Patients at Increased Risk During ICD Procedures
>> Improving the Quality of ACS Care
The Particulars: Transcatheter aortic valve implantation (TAVI) involves insertion of a bioprosthetic valve into a diseased native aortic valve and represents a potentially less invasive option than surgical replacement. Currently, TAVI has been used mostly in non-operable patients.
Data Breakdown: A study was conducted in high-risk patients with severe aortic stenosis who underwent TAVI at 44 centers. Major adverse cardiac and cerebrovascular events at 30-days follow-up occurred in 8.3% of patients receiving TAVI. Total mortality, cardiac mortality, stroke, and life-threatening or disabling bleeding rates were 4.5%, 2.2%, 2.9%, and 4.9%, respectively. Persistent, significant improvements in aortic valve function were also observed.
Take Home Pearl: In high operative risk and non-operable patients, TAVI appears to be safe and effective.
The Particulars: CABG is one of the most commonly performed cardiac operations, but small randomized trials and meta-analyses have yet to determine conclusively if less-invasive off-pump CABG has better outcomes than on-pump CABG.
Data Breakdown: A trial of nearly 5,000 patients with coronary artery disease randomized patients to on-pump or off-pump CABG. The composite outcome of death, heart attack, kidney failure, and stroke at 30 days post-bypass had a rate of 9.9% in the off-pump group, compared with a statistically neutral 10.3% rate for the on-pump group.
Take Home Pearl: The outcomes of off-pump CABG appear to be similar to those of on-pump CABG.
The Particulars: Approximately 50,000 Americans aged 75 and older undergo open-heart surgery for aortic stenosis annually. However, many older patients forgo this surgery because of comorbid conditions, age, or preference. Transcatheter aortic valve replacement (TAVR) represents a less-invasive option for this patient population.
Data Breakdown: In the PARTNER trial, high-risk older adults were randomized to open-heart surgery or TAVR. The rate of death from any cause was 35.0% for the open-heart surgery group, compared with 33.9% for the TAVR group. Although the 30-day stroke risk showed a benefit for open-heart surgery, no significant difference was seen in stroke risk between the TAVR and open-heart surgery groups when assessed at 2 years.
Take Home Pearl: Mortality and durability outcomes for open-heart surgery and TAVR performed on older adults with aortic stenosis appear to be comparable at 2 years.
The Particulars: Obese patients with diabetes have traditionally been treated with a polypharmacy approach. It has been hypothesized that surgery may be a more effective approach to treating obese patients with type 2 diabetes.
Data Breakdown: In obese patients with type 2 diabetes, researchers compared laparoscopic gastric bypass plus medical therapy and sleeve gastrectomy plus medical therapy to intensive medical therapy alone. The goal was to determine efficacy in helping patients with uncontrolled type 2 diabetes achieve target A1C goals. Patients in the surgical groups were three-to-four times more likely to achieve glycemic control at 1 year than those who received intensive medical therapy alone. Weight loss for those who underwent surgery averaged 55 to 64 lbs, compared with 12 lbs for those who underwent medical therapy alone.
Take Home Pearls: At 1 year follow-up, bariatric surgery appears to be more effective in managing uncontrolled type 2 diabetes in overweight or obese patients than intensive medical management alone. Those undergoing bariatric surgery appeared to lose significantly more weight than those receiving intensive medical therapy only.
The Particulars: In recent years, much focus has been placed on the outcomes of surgery in obese patients when using implantable-cardioverter defibrillators (ICDs). Far less attention has been paid to the risks of implanting ICDs among underweight patients and those of small stature.
Data Breakdown: A review of 83,000 cases investigated the influence of body size on patient outcomes following ICD implantation. When compared with normal-weight patients, obese patients were not at high risk for adverse events. Conversely, patients receiving ICDs who had a low BMI experienced longer hospital stays when compared with obese and normal-weight participants. They were also twice as likely to experience complications or die during or shortly after implantation.
Take Home Pearl: Patients with a low BMI who receive an ICD appear to be at increased risk for long hospital stays, complications, and death.
The Particulars: At some facilities, the uptake of evidence-based practices for acute coronary syndrome (ACS) may be lacking. Implementing a quality improvement (QI) program may increase use of evidence-based therapies and reduce major cardiovascular events in patients with ACS.
Data Breakdown: Brazilian researchers studied the use of a QI program that included 1) educational materials explaining recommendations for clinical care, 2) a trained case manager responsible for ensuring that all the recommended interventions were used appropriately, 3) reminder systems, and 4) practical training. At hospitals where the program was implemented, 67.9% of eligible patients received all recommended acute interventions, compared with 49.5% of those at hospitals that did not participate in the program.
Take Home Pearl: A program designed to improve the quality of ACS care appears to increase adherence with evidence-based practices.
Readings & Resources (click to view)
For more information on these studies and others that were presented at ACC.12, go to http://www.acc2012.org/.