Cardiothoracic

An acute aortic tear can be lethal, and more cardiac surgeons are favoring extended aortic arch replacement in these cases. Cardiac surgeons have tried many different arch replacement techniques, but en bloc repair and double- or triple-branch stent grafting carry significant risks, so a team of cardiac surgeons in Beijing has reported good 2-year results with a novel technique that combines stented elephant-trunk implantation with preservation of key vessels.

The technique accomplishes total arch replacement with the stent while preserving the autologous brachiocephalic vessels.

“This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic patch wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results,” wrote Dr. Li-Zhong Sun and colleagues at Beijing’s Capital Medical University (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.002]).

There are four keys to the procedure:

• The use of forceps to grasp the stent-free sewing edge of the stented elephant trunk and straightening of the spiral shaped Dacron graft to approximately 3 cm.

• Preservation of the native brachiocephalic vessels.

• Creating a residual aortic wall containing the innominate artery and LCCA that’s as small as possible.

• An end-to-side anastomosis between the left subclavian artery (LSCA) and the left common carotid artery (LCCA), a key junction in their technique.

The 20 study subjects had surgery within 2 weeks of the onset of pain. All 20 were discharged after the procedure, and in a mean follow-up period of 26 months, 18 had good outcomes while 1 patient had thoracoabdominal aortic replacement 9 months after the initial surgery (1 patient was lost to follow-up).

The researchers used computed tomography to confirm patency of the anastomosis between the LSCA and LCCA.

In 2 of the 20 patients, the aorta was normal with aortic dissection limited to the descending aorta. In the remaining patients, the investigators observed thrombus obliteration of the false lumen around the surgical graft in 16, partial thrombosis in 1 and patency in 1.

The surgical technique exposes the right axillary artery through a right subclavicular incision and a median sternotomy, then dissects and exposes the brachiocephalic vessels and the transverse arch. Dissection of the LSCA and LCCA is the key step in making the end-to-end anastomosis between the two vessels. The researchers accomplished this by partially transecting the sternocleidomastoid muscle and other cervical muscles.

Dr. Sun and coauthors said that a separated graft technique offers a number of advantages over other techniques for aortic arch reconstruction. While en bloc repair preserves the native brachiocephalic vessels and, thus, results in long-term patency, the technique carries risk for postoperative rupture of the aortic patch containing the brachiocephalic vessels. Double- or triple-branched stent grafting has resulted in shifting or kinking of the graft and eventually graft occlusion or aortic disruption.

The authors acknowledged the study’s small sample size, and that the outcomes are “preliminary.” They said long-term follow-up would be required to confirm the outcomes.

They had no disclosures to report.

An acute aortic tear can be lethal, and more cardiac surgeons are favoring extended aortic arch replacement in these cases. Cardiac surgeons have tried many different arch replacement techniques, but en bloc repair and double- or triple-branch stent grafting carry significant risks, so a team of cardiac surgeons in Beijing has reported good 2-year results with a novel technique that combines stented elephant-trunk implantation with preservation of key vessels.

The technique accomplishes total arch replacement with the stent while preserving the autologous brachiocephalic vessels.

“This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic patch wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results,” wrote Dr. Li-Zhong Sun and colleagues at Beijing’s Capital Medical University (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.002]).

There are four keys to the procedure:

• The use of forceps to grasp the stent-free sewing edge of the stented elephant trunk and straightening of the spiral shaped Dacron graft to approximately 3 cm.

• Preservation of the native brachiocephalic vessels.

• Creating a residual aortic wall containing the innominate artery and LCCA that’s as small as possible.

• An end-to-side anastomosis between the left subclavian artery (LSCA) and the left common carotid artery (LCCA), a key junction in their technique.

The 20 study subjects had surgery within 2 weeks of the onset of pain. All 20 were discharged after the procedure, and in a mean follow-up period of 26 months, 18 had good outcomes while 1 patient had thoracoabdominal aortic replacement 9 months after the initial surgery (1 patient was lost to follow-up).

The researchers used computed tomography to confirm patency of the anastomosis between the LSCA and LCCA.

In 2 of the 20 patients, the aorta was normal with aortic dissection limited to the descending aorta. In the remaining patients, the investigators observed thrombus obliteration of the false lumen around the surgical graft in 16, partial thrombosis in 1 and patency in 1.

The surgical technique exposes the right axillary artery through a right subclavicular incision and a median sternotomy, then dissects and exposes the brachiocephalic vessels and the transverse arch. Dissection of the LSCA and LCCA is the key step in making the end-to-end anastomosis between the two vessels. The researchers accomplished this by partially transecting the sternocleidomastoid muscle and other cervical muscles.

Dr. Sun and coauthors said that a separated graft technique offers a number of advantages over other techniques for aortic arch reconstruction. While en bloc repair preserves the native brachiocephalic vessels and, thus, results in long-term patency, the technique carries risk for postoperative rupture of the aortic patch containing the brachiocephalic vessels. Double- or triple-branched stent grafting has resulted in shifting or kinking of the graft and eventually graft occlusion or aortic disruption.

The authors acknowledged the study’s small sample size, and that the outcomes are “preliminary.” They said long-term follow-up would be required to confirm the outcomes.

They had no disclosures to report.

An acute aortic tear can be lethal, and more cardiac surgeons are favoring extended aortic arch replacement in these cases. Cardiac surgeons have tried many different arch replacement techniques, but en bloc repair and double- or triple-branch stent grafting carry significant risks, so a team of cardiac surgeons in Beijing has reported good 2-year results with a novel technique that combines stented elephant-trunk implantation with preservation of key vessels.

The technique accomplishes total arch replacement with the stent while preserving the autologous brachiocephalic vessels.

“This technique simplified hemostasis and anastomosis, reduced the size of the residual aortic patch wall, and preserved the autologous brachiocephalic vessels, yielding satisfactory surgical results,” wrote Dr. Li-Zhong Sun and colleagues at Beijing’s Capital Medical University (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.002]).

There are four keys to the procedure:

• The use of forceps to grasp the stent-free sewing edge of the stented elephant trunk and straightening of the spiral shaped Dacron graft to approximately 3 cm.

• Preservation of the native brachiocephalic vessels.

• Creating a residual aortic wall containing the innominate artery and LCCA that’s as small as possible.

• An end-to-side anastomosis between the left subclavian artery (LSCA) and the left common carotid artery (LCCA), a key junction in their technique.

The 20 study subjects had surgery within 2 weeks of the onset of pain. All 20 were discharged after the procedure, and in a mean follow-up period of 26 months, 18 had good outcomes while 1 patient had thoracoabdominal aortic replacement 9 months after the initial surgery (1 patient was lost to follow-up).

The researchers used computed tomography to confirm patency of the anastomosis between the LSCA and LCCA.

In 2 of the 20 patients, the aorta was normal with aortic dissection limited to the descending aorta. In the remaining patients, the investigators observed thrombus obliteration of the false lumen around the surgical graft in 16, partial thrombosis in 1 and patency in 1.

The surgical technique exposes the right axillary artery through a right subclavicular incision and a median sternotomy, then dissects and exposes the brachiocephalic vessels and the transverse arch. Dissection of the LSCA and LCCA is the key step in making the end-to-end anastomosis between the two vessels. The researchers accomplished this by partially transecting the sternocleidomastoid muscle and other cervical muscles.

Dr. Sun and coauthors said that a separated graft technique offers a number of advantages over other techniques for aortic arch reconstruction. While en bloc repair preserves the native brachiocephalic vessels and, thus, results in long-term patency, the technique carries risk for postoperative rupture of the aortic patch containing the brachiocephalic vessels. Double- or triple-branched stent grafting has resulted in shifting or kinking of the graft and eventually graft occlusion or aortic disruption.

The authors acknowledged the study’s small sample size, and that the outcomes are “preliminary.” They said long-term follow-up would be required to confirm the outcomes.

They had no disclosures to report.

CHICAGO – Age greater than 76 years, plus preoperative creatinine greater than 2 mg/dL, blood pH less than 7.2, and systolic pressure at any point below 70 mm Hg collectively predicted 100% mortality with open or endovascular repair of ruptured abdominal aortic aneurysms, according to a new mortality risk score from Harborview Medical Center in Seattle.

Meeting all four criteria gives the maximum score of 4. Any one of the factors alone – a score of 1 – predicted 30% mortality with open repair and 9% with endovascular aneurysm repair (EVAR); a 2 predicted 80% mortality with open repair and 37% with EVAR; and a 3 predicted 82% mortality with open repair and 70% with EVAR.

Vascular surgeons at Harborview developed the system so they’d know whether to recommend transport or comfort care for ruptured abdominal aortic aneurysms (AAAs). The Level 1 trauma center serves more than a quarter of the U.S. landmass, and handles about 30-40 ruptured AAA’s annually. It’s not uncommon for patients to be flown in from Alaska.

Existing risk scores haven’t been validated for EVAR or rely on intraoperative variables, so they aren’t much help when counseling patients and referring physicians on what to do.

“Our ruptured AAA mortality risk score is based on four variables readily assessed preoperatively, allows accurate prediction of in-hospital mortality after repair of ruptured AAAs in the EVAR-first era, and does so better than any score thus published. It’s clinically relevant to the decision to transport and helps guide difficult discussions with patients and their families,” said investigator Dr. Ty Garland, chief vascular surgery resident at the University of Washington, Seattle.

When using the new risk score. “we don’t ever block transfer, but we have discussions with referring providers and in several cases with patients and their families over the telephone.” When the situation is hopeless, “we explain the data.” Twice in the past 6 months, patients have opted to spend their last hours at home with their families, Dr. Garland said at the Society for Vascular Surgery’s annual meeting.

To develop their system, the investigators culled through 37,000 variables from 303 ruptured AAA patients treated at Harborview from 2002-2013. Fifteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Overall, 30-day mortality was 54% for open repair and 22% for EVAR.

On multivariate analysis, the team isolated the four preoperative variables most predictive of death. Preoperative creatinine greater than 2 mg/dL almost quadrupled the risk (odds ratio 3.7; P < .001); systolic blood pressure less than 70 mm Hg nearly tripled it (OR 2.7; P = .002); and pH less than 7.2 (OR 2.6; P = .009) and age greater than 76 years (OR 2.1; P = .011) more than doubled it.

The investigators then checked their results against the Vascular Study Group of New England Cardiac Index, Glasgow Aneurysm Score, and Edinburgh Ruptured Aneurysm Score. “Our preoperative risk score was most predictive of death, with an area under the curve of 0.76,” Dr. Garland said.

There was no outside funding for the work and Dr. Garland has no disclosures.

[email protected]

CHICAGO – Age greater than 76 years, plus preoperative creatinine greater than 2 mg/dL, blood pH less than 7.2, and systolic pressure at any point below 70 mm Hg collectively predicted 100% mortality with open or endovascular repair of ruptured abdominal aortic aneurysms, according to a new mortality risk score from Harborview Medical Center in Seattle.

Meeting all four criteria gives the maximum score of 4. Any one of the factors alone – a score of 1 – predicted 30% mortality with open repair and 9% with endovascular aneurysm repair (EVAR); a 2 predicted 80% mortality with open repair and 37% with EVAR; and a 3 predicted 82% mortality with open repair and 70% with EVAR.

Vascular surgeons at Harborview developed the system so they’d know whether to recommend transport or comfort care for ruptured abdominal aortic aneurysms (AAAs). The Level 1 trauma center serves more than a quarter of the U.S. landmass, and handles about 30-40 ruptured AAA’s annually. It’s not uncommon for patients to be flown in from Alaska.

Existing risk scores haven’t been validated for EVAR or rely on intraoperative variables, so they aren’t much help when counseling patients and referring physicians on what to do.

“Our ruptured AAA mortality risk score is based on four variables readily assessed preoperatively, allows accurate prediction of in-hospital mortality after repair of ruptured AAAs in the EVAR-first era, and does so better than any score thus published. It’s clinically relevant to the decision to transport and helps guide difficult discussions with patients and their families,” said investigator Dr. Ty Garland, chief vascular surgery resident at the University of Washington, Seattle.

When using the new risk score. “we don’t ever block transfer, but we have discussions with referring providers and in several cases with patients and their families over the telephone.” When the situation is hopeless, “we explain the data.” Twice in the past 6 months, patients have opted to spend their last hours at home with their families, Dr. Garland said at the Society for Vascular Surgery’s annual meeting.

To develop their system, the investigators culled through 37,000 variables from 303 ruptured AAA patients treated at Harborview from 2002-2013. Fifteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Overall, 30-day mortality was 54% for open repair and 22% for EVAR.

On multivariate analysis, the team isolated the four preoperative variables most predictive of death. Preoperative creatinine greater than 2 mg/dL almost quadrupled the risk (odds ratio 3.7; P < .001); systolic blood pressure less than 70 mm Hg nearly tripled it (OR 2.7; P = .002); and pH less than 7.2 (OR 2.6; P = .009) and age greater than 76 years (OR 2.1; P = .011) more than doubled it.

The investigators then checked their results against the Vascular Study Group of New England Cardiac Index, Glasgow Aneurysm Score, and Edinburgh Ruptured Aneurysm Score. “Our preoperative risk score was most predictive of death, with an area under the curve of 0.76,” Dr. Garland said.

There was no outside funding for the work and Dr. Garland has no disclosures.

[email protected]

CHICAGO – Age greater than 76 years, plus preoperative creatinine greater than 2 mg/dL, blood pH less than 7.2, and systolic pressure at any point below 70 mm Hg collectively predicted 100% mortality with open or endovascular repair of ruptured abdominal aortic aneurysms, according to a new mortality risk score from Harborview Medical Center in Seattle.

Meeting all four criteria gives the maximum score of 4. Any one of the factors alone – a score of 1 – predicted 30% mortality with open repair and 9% with endovascular aneurysm repair (EVAR); a 2 predicted 80% mortality with open repair and 37% with EVAR; and a 3 predicted 82% mortality with open repair and 70% with EVAR.

Vascular surgeons at Harborview developed the system so they’d know whether to recommend transport or comfort care for ruptured abdominal aortic aneurysms (AAAs). The Level 1 trauma center serves more than a quarter of the U.S. landmass, and handles about 30-40 ruptured AAA’s annually. It’s not uncommon for patients to be flown in from Alaska.

Existing risk scores haven’t been validated for EVAR or rely on intraoperative variables, so they aren’t much help when counseling patients and referring physicians on what to do.

“Our ruptured AAA mortality risk score is based on four variables readily assessed preoperatively, allows accurate prediction of in-hospital mortality after repair of ruptured AAAs in the EVAR-first era, and does so better than any score thus published. It’s clinically relevant to the decision to transport and helps guide difficult discussions with patients and their families,” said investigator Dr. Ty Garland, chief vascular surgery resident at the University of Washington, Seattle.

When using the new risk score. “we don’t ever block transfer, but we have discussions with referring providers and in several cases with patients and their families over the telephone.” When the situation is hopeless, “we explain the data.” Twice in the past 6 months, patients have opted to spend their last hours at home with their families, Dr. Garland said at the Society for Vascular Surgery’s annual meeting.

To develop their system, the investigators culled through 37,000 variables from 303 ruptured AAA patients treated at Harborview from 2002-2013. Fifteen patients died in the emergency department, en route to surgery, or after choosing comfort care. Overall, 30-day mortality was 54% for open repair and 22% for EVAR.

On multivariate analysis, the team isolated the four preoperative variables most predictive of death. Preoperative creatinine greater than 2 mg/dL almost quadrupled the risk (odds ratio 3.7; P < .001); systolic blood pressure less than 70 mm Hg nearly tripled it (OR 2.7; P = .002); and pH less than 7.2 (OR 2.6; P = .009) and age greater than 76 years (OR 2.1; P = .011) more than doubled it.

The investigators then checked their results against the Vascular Study Group of New England Cardiac Index, Glasgow Aneurysm Score, and Edinburgh Ruptured Aneurysm Score. “Our preoperative risk score was most predictive of death, with an area under the curve of 0.76,” Dr. Garland said.

There was no outside funding for the work and Dr. Garland has no disclosures.

[email protected]

Fewer than one in 10 elderly patients with a low ejection fraction after myocardial infarction who are eligible to receive an implantable cardioverter-defibrillator actually receive one within a year of their myocardial infarction, a study has found.

The retrospective observational study of 10,318 patients aged over 65 years who had experienced a myocardial infarction and had an ejection fraction of 35% or less showed only 8.1% received an implantable cardioverter-defibrillator (ICD) within a year of their MI, even though implantation within a year was associated with a 36% reduction in mortality at 2 years.

Those patients who did receive an ICD were more likely to have had a prior coronary artery bypass graft, had higher peak troponin levels, experienced in-hospital cardiogenic shock, or had a cardiology follow-up within 2 weeks of discharge, according to the paper published June 23 in JAMA.

“Individualized shared decision making, taking into context the patient’s quality of life, treatment goals, and preferences, is critical, because ICD therapy may shift death from a sudden event to a more gradual comorbid process,” wrote Dr. Sean D. Pokorney, of Duke University Medical Center, Durham, N.C., and co-authors (JAMA 2015;313:2433-40 [doi: 10.1001/jama.2015.6409]).

The study was supported by the Agency for Healthcare Research& Quality, and Boston Scientific. Some authors declared research grants, honoraria, advisory board positions, and consultancies with private industry.

Fewer than one in 10 elderly patients with a low ejection fraction after myocardial infarction who are eligible to receive an implantable cardioverter-defibrillator actually receive one within a year of their myocardial infarction, a study has found.

The retrospective observational study of 10,318 patients aged over 65 years who had experienced a myocardial infarction and had an ejection fraction of 35% or less showed only 8.1% received an implantable cardioverter-defibrillator (ICD) within a year of their MI, even though implantation within a year was associated with a 36% reduction in mortality at 2 years.

Those patients who did receive an ICD were more likely to have had a prior coronary artery bypass graft, had higher peak troponin levels, experienced in-hospital cardiogenic shock, or had a cardiology follow-up within 2 weeks of discharge, according to the paper published June 23 in JAMA.

“Individualized shared decision making, taking into context the patient’s quality of life, treatment goals, and preferences, is critical, because ICD therapy may shift death from a sudden event to a more gradual comorbid process,” wrote Dr. Sean D. Pokorney, of Duke University Medical Center, Durham, N.C., and co-authors (JAMA 2015;313:2433-40 [doi: 10.1001/jama.2015.6409]).

The study was supported by the Agency for Healthcare Research& Quality, and Boston Scientific. Some authors declared research grants, honoraria, advisory board positions, and consultancies with private industry.

Fewer than one in 10 elderly patients with a low ejection fraction after myocardial infarction who are eligible to receive an implantable cardioverter-defibrillator actually receive one within a year of their myocardial infarction, a study has found.

The retrospective observational study of 10,318 patients aged over 65 years who had experienced a myocardial infarction and had an ejection fraction of 35% or less showed only 8.1% received an implantable cardioverter-defibrillator (ICD) within a year of their MI, even though implantation within a year was associated with a 36% reduction in mortality at 2 years.

Those patients who did receive an ICD were more likely to have had a prior coronary artery bypass graft, had higher peak troponin levels, experienced in-hospital cardiogenic shock, or had a cardiology follow-up within 2 weeks of discharge, according to the paper published June 23 in JAMA.

“Individualized shared decision making, taking into context the patient’s quality of life, treatment goals, and preferences, is critical, because ICD therapy may shift death from a sudden event to a more gradual comorbid process,” wrote Dr. Sean D. Pokorney, of Duke University Medical Center, Durham, N.C., and co-authors (JAMA 2015;313:2433-40 [doi: 10.1001/jama.2015.6409]).

The study was supported by the Agency for Healthcare Research& Quality, and Boston Scientific. Some authors declared research grants, honoraria, advisory board positions, and consultancies with private industry.

As “simple procedures” diminish, should thoracic surgeons in training programs be mandated to allow residents to operate on patients in order to satisfy board requirements? This was the question posed during an ethics debate at the annual meeting of the Society of Thoracic Surgeons.

It is ethical, and it is necessary.

BY RICHARD G. OHYE, M.D.

The linchpin of this discussion is the “obligation,” which is defined as “a course of action that someone is required to take, whether legal or moral” to have residents perform surgery. My position is that, yes, we do have such a mandate.

I doubt that Dr. Jaggers and I would disagree that teaching residents is something we do as academic surgeons. The devil is in the details. Among our concerns are patient safety and closer scrutiny on surgical practices due to public reporting, which makes everything we do readily available. Further, simple, straightforward cases are going away; interventional cardiologists are doing lots of stents, mitral valves, and atrial septal defect closures, so those kinds of procedures are going away.

Looking at case logs from congenital cardiac and CT residents at our institution, however, there are still incomplete canals, tricuspid valve repairs, mitral valve repairs and replacements, aortic valve repairs, patent ductus arteriosus repairs, vascular rings, pulmonary valve replacements, and conduits. Residents are capable of doing these procedures; they are incredibly talented individuals and you just have to let them operate.

In addition, our results – and more importantly, our patients – have not suffered. We let our residents do between one-third and one-half of our cases, and the cases only count if they’re skin-to-skin. Our results, compared by STAT category, compare favorably with STS benchmarks and are either at or below expected values. By the end of this year, our expected mortality should be about 23%, but our observed mortality is less than half that value with the residents doing lots of cases.

So what about the ethics – who would you want operating on you? There is an ethical dilemma that goes along with medical education because no matter how good my residents may be, I am more experienced. I can do every procedure faster and “better” than they can. But the teaching of students is not a new concept, it’s even in the Hippocratic Oath, so this is an old and well-accepted practice.

There is a strong parallel between medical education and medical research. We still have to follow all of those important guidelines we have for medical research – do what’s right for the patient and exercise good judgment. We must not just “do no harm.” We must actively do good.

Academic surgeons have an obligation to teach. We take care of patients, do research to push the whole field forward, and educate to bring up the next generation of doctors. The cases for residents to perform are all there – yes, we’re a big program, but even smaller programs should see plenty of cases – and I think I’ve shown that these can be performed safely and yield excellent results. As long as the results are good, you don’t need to worry about public scrutiny. The case for medical education is similar to that of medical research: It is ethical, and it is necessary.

Dr. Ohye is head of the pediatric cardiovascular surgery division and surgical director of the pediatric heart transplant program of the University of Michigan, in Ann Arbor; he argued in support of a mandate.

Patients may not benefit, and may actually be harmed

BY JAMES JAGGERS, M.D.

The central issue in this debate is whether or not the surgeon’s responsibility as an educator and member of the training program overrides the surgeon’s responsibility to provide the patient with the best possible outcome. Put another way, should the responsibility to treat the patient to the best of the surgeon’s ability be subordinated to the success and survival of the training program for the sole purpose of giving the resident sufficient operative experience to be board eligible?

Both versions of the Hippocratic Oath and the more recent Declaration of Geneva, the AMA’s Code of Ethics, and the ACGME Mission Statement clearly enforce that the primary responsibility of the physician is to the patient, while also endorsing physician responsibility to community via service and education. Using patients as a means to an end – in this case, to satisfy board requirements – and to do so without patients’ explicit consent, violates the fundamental principle of respect for individuals.

I will not argue that resident surgery can be safely performed without risking harm to the patient. If the surgical instructor could exercise complete control over a procedure and correct any mistakes that the trainees made so that the procedure has the same outcome, then it would be ethically allowable. The surgical instructor must be confident that his residents are fully capable of performing the surgery on their own, otherwise it not ethical to subject the patient to this risk.

Dr. Ohye and I are both part of larger divisions that have their own obligations, and we have experience training residents at all levels. We have similar backgrounds, and we both benefited from having mentors who sometimes had masochistic patience in helping us get through surgeries that we probably weren’t ready for. I’m certain that those of us in academic medicine training programs believe that graduated involvement of trainees in patient care is an integral part of the surgical education process, and is critical to society as a whole.

However, the fact that patients may not directly benefit, and may actually be harmed, from the resident’s involvement in surgery creates an ethical dilemma. There is little literature to guide us through this dilemma. Professional societies only advise generally, noting that participation should be voluntary, without providing specifics. Regulatory boards simply set minimum requirements without providing guidance for the educational process. While the ACGME and the residency review committees oversee resident training, the responsibility for successful training is left largely to individual surgeons and individual programs. It’s only recently that the TSDA (Thoracic Surgery Directors Association) adopted the milestone concept that hopefully will help resolve some of these issues.

Consider a medium-sized program of around 300 patients: A difference of just one death, such as 10 or 11 per year, is the difference between being above or below the STS mean. Now that may not be statistically significant, but if you put that number on your website, it becomes important. It’s true that the practice of congenital heart surgery has changed over the last 15-20 years. Our program has seen resident cases roughly halved in the last 10 years. Most patients are operated on at a younger age, palliation is very rare. These are not meant to be excuses for not training residents – they’re just the reality.

The outcomes of surgeries are increasingly scrutinized by regulatory agencies and sources of public reporting. Competition between programs is intense. Patients, parents, and referring providers have become increasingly aware of outcomes to the point that it’s actually not unusual for a patient to ask “What’s your surgical site infection rate? What are the chances I’ll need to have a pacemaker? What are your individual results?” Insurance companies are starting to ask for financial data, economically profiling you to ensure that you’re being as efficient as possible. All of these things are contrary to our ability to train residents effectively.

Because of fear of taking too long or increasing complications, some surgeons say they are much more likely to accept residual defects when operating with trainees. It’s only with familiarity and time that the highly skilled attending and properly motivated resident may work in tandem and produce the best outcome – but not in the 10 cases the American Board of Thoracic Surgery requires.

Dr. Jaggers is the Barton-Elliman Chair in Pediatric Cardiothoracic Surgery at the University of Colorado and co–medical director of The Heart Institute at Children’s Hospital Colorado in Aurora. He argued against having residents perform surgery for board certification.

[email protected]

As “simple procedures” diminish, should thoracic surgeons in training programs be mandated to allow residents to operate on patients in order to satisfy board requirements? This was the question posed during an ethics debate at the annual meeting of the Society of Thoracic Surgeons.

It is ethical, and it is necessary.

BY RICHARD G. OHYE, M.D.

The linchpin of this discussion is the “obligation,” which is defined as “a course of action that someone is required to take, whether legal or moral” to have residents perform surgery. My position is that, yes, we do have such a mandate.

I doubt that Dr. Jaggers and I would disagree that teaching residents is something we do as academic surgeons. The devil is in the details. Among our concerns are patient safety and closer scrutiny on surgical practices due to public reporting, which makes everything we do readily available. Further, simple, straightforward cases are going away; interventional cardiologists are doing lots of stents, mitral valves, and atrial septal defect closures, so those kinds of procedures are going away.

Looking at case logs from congenital cardiac and CT residents at our institution, however, there are still incomplete canals, tricuspid valve repairs, mitral valve repairs and replacements, aortic valve repairs, patent ductus arteriosus repairs, vascular rings, pulmonary valve replacements, and conduits. Residents are capable of doing these procedures; they are incredibly talented individuals and you just have to let them operate.

In addition, our results – and more importantly, our patients – have not suffered. We let our residents do between one-third and one-half of our cases, and the cases only count if they’re skin-to-skin. Our results, compared by STAT category, compare favorably with STS benchmarks and are either at or below expected values. By the end of this year, our expected mortality should be about 23%, but our observed mortality is less than half that value with the residents doing lots of cases.

So what about the ethics – who would you want operating on you? There is an ethical dilemma that goes along with medical education because no matter how good my residents may be, I am more experienced. I can do every procedure faster and “better” than they can. But the teaching of students is not a new concept, it’s even in the Hippocratic Oath, so this is an old and well-accepted practice.

There is a strong parallel between medical education and medical research. We still have to follow all of those important guidelines we have for medical research – do what’s right for the patient and exercise good judgment. We must not just “do no harm.” We must actively do good.

Academic surgeons have an obligation to teach. We take care of patients, do research to push the whole field forward, and educate to bring up the next generation of doctors. The cases for residents to perform are all there – yes, we’re a big program, but even smaller programs should see plenty of cases – and I think I’ve shown that these can be performed safely and yield excellent results. As long as the results are good, you don’t need to worry about public scrutiny. The case for medical education is similar to that of medical research: It is ethical, and it is necessary.

Dr. Ohye is head of the pediatric cardiovascular surgery division and surgical director of the pediatric heart transplant program of the University of Michigan, in Ann Arbor; he argued in support of a mandate.

Patients may not benefit, and may actually be harmed

BY JAMES JAGGERS, M.D.

The central issue in this debate is whether or not the surgeon’s responsibility as an educator and member of the training program overrides the surgeon’s responsibility to provide the patient with the best possible outcome. Put another way, should the responsibility to treat the patient to the best of the surgeon’s ability be subordinated to the success and survival of the training program for the sole purpose of giving the resident sufficient operative experience to be board eligible?

Both versions of the Hippocratic Oath and the more recent Declaration of Geneva, the AMA’s Code of Ethics, and the ACGME Mission Statement clearly enforce that the primary responsibility of the physician is to the patient, while also endorsing physician responsibility to community via service and education. Using patients as a means to an end – in this case, to satisfy board requirements – and to do so without patients’ explicit consent, violates the fundamental principle of respect for individuals.

I will not argue that resident surgery can be safely performed without risking harm to the patient. If the surgical instructor could exercise complete control over a procedure and correct any mistakes that the trainees made so that the procedure has the same outcome, then it would be ethically allowable. The surgical instructor must be confident that his residents are fully capable of performing the surgery on their own, otherwise it not ethical to subject the patient to this risk.

Dr. Ohye and I are both part of larger divisions that have their own obligations, and we have experience training residents at all levels. We have similar backgrounds, and we both benefited from having mentors who sometimes had masochistic patience in helping us get through surgeries that we probably weren’t ready for. I’m certain that those of us in academic medicine training programs believe that graduated involvement of trainees in patient care is an integral part of the surgical education process, and is critical to society as a whole.

However, the fact that patients may not directly benefit, and may actually be harmed, from the resident’s involvement in surgery creates an ethical dilemma. There is little literature to guide us through this dilemma. Professional societies only advise generally, noting that participation should be voluntary, without providing specifics. Regulatory boards simply set minimum requirements without providing guidance for the educational process. While the ACGME and the residency review committees oversee resident training, the responsibility for successful training is left largely to individual surgeons and individual programs. It’s only recently that the TSDA (Thoracic Surgery Directors Association) adopted the milestone concept that hopefully will help resolve some of these issues.

Consider a medium-sized program of around 300 patients: A difference of just one death, such as 10 or 11 per year, is the difference between being above or below the STS mean. Now that may not be statistically significant, but if you put that number on your website, it becomes important. It’s true that the practice of congenital heart surgery has changed over the last 15-20 years. Our program has seen resident cases roughly halved in the last 10 years. Most patients are operated on at a younger age, palliation is very rare. These are not meant to be excuses for not training residents – they’re just the reality.

The outcomes of surgeries are increasingly scrutinized by regulatory agencies and sources of public reporting. Competition between programs is intense. Patients, parents, and referring providers have become increasingly aware of outcomes to the point that it’s actually not unusual for a patient to ask “What’s your surgical site infection rate? What are the chances I’ll need to have a pacemaker? What are your individual results?” Insurance companies are starting to ask for financial data, economically profiling you to ensure that you’re being as efficient as possible. All of these things are contrary to our ability to train residents effectively.

Because of fear of taking too long or increasing complications, some surgeons say they are much more likely to accept residual defects when operating with trainees. It’s only with familiarity and time that the highly skilled attending and properly motivated resident may work in tandem and produce the best outcome – but not in the 10 cases the American Board of Thoracic Surgery requires.

Dr. Jaggers is the Barton-Elliman Chair in Pediatric Cardiothoracic Surgery at the University of Colorado and co–medical director of The Heart Institute at Children’s Hospital Colorado in Aurora. He argued against having residents perform surgery for board certification.

[email protected]

As “simple procedures” diminish, should thoracic surgeons in training programs be mandated to allow residents to operate on patients in order to satisfy board requirements? This was the question posed during an ethics debate at the annual meeting of the Society of Thoracic Surgeons.

It is ethical, and it is necessary.

BY RICHARD G. OHYE, M.D.

The linchpin of this discussion is the “obligation,” which is defined as “a course of action that someone is required to take, whether legal or moral” to have residents perform surgery. My position is that, yes, we do have such a mandate.

I doubt that Dr. Jaggers and I would disagree that teaching residents is something we do as academic surgeons. The devil is in the details. Among our concerns are patient safety and closer scrutiny on surgical practices due to public reporting, which makes everything we do readily available. Further, simple, straightforward cases are going away; interventional cardiologists are doing lots of stents, mitral valves, and atrial septal defect closures, so those kinds of procedures are going away.

Looking at case logs from congenital cardiac and CT residents at our institution, however, there are still incomplete canals, tricuspid valve repairs, mitral valve repairs and replacements, aortic valve repairs, patent ductus arteriosus repairs, vascular rings, pulmonary valve replacements, and conduits. Residents are capable of doing these procedures; they are incredibly talented individuals and you just have to let them operate.

In addition, our results – and more importantly, our patients – have not suffered. We let our residents do between one-third and one-half of our cases, and the cases only count if they’re skin-to-skin. Our results, compared by STAT category, compare favorably with STS benchmarks and are either at or below expected values. By the end of this year, our expected mortality should be about 23%, but our observed mortality is less than half that value with the residents doing lots of cases.

So what about the ethics – who would you want operating on you? There is an ethical dilemma that goes along with medical education because no matter how good my residents may be, I am more experienced. I can do every procedure faster and “better” than they can. But the teaching of students is not a new concept, it’s even in the Hippocratic Oath, so this is an old and well-accepted practice.

There is a strong parallel between medical education and medical research. We still have to follow all of those important guidelines we have for medical research – do what’s right for the patient and exercise good judgment. We must not just “do no harm.” We must actively do good.

Academic surgeons have an obligation to teach. We take care of patients, do research to push the whole field forward, and educate to bring up the next generation of doctors. The cases for residents to perform are all there – yes, we’re a big program, but even smaller programs should see plenty of cases – and I think I’ve shown that these can be performed safely and yield excellent results. As long as the results are good, you don’t need to worry about public scrutiny. The case for medical education is similar to that of medical research: It is ethical, and it is necessary.

Dr. Ohye is head of the pediatric cardiovascular surgery division and surgical director of the pediatric heart transplant program of the University of Michigan, in Ann Arbor; he argued in support of a mandate.

Patients may not benefit, and may actually be harmed

BY JAMES JAGGERS, M.D.

The central issue in this debate is whether or not the surgeon’s responsibility as an educator and member of the training program overrides the surgeon’s responsibility to provide the patient with the best possible outcome. Put another way, should the responsibility to treat the patient to the best of the surgeon’s ability be subordinated to the success and survival of the training program for the sole purpose of giving the resident sufficient operative experience to be board eligible?

Both versions of the Hippocratic Oath and the more recent Declaration of Geneva, the AMA’s Code of Ethics, and the ACGME Mission Statement clearly enforce that the primary responsibility of the physician is to the patient, while also endorsing physician responsibility to community via service and education. Using patients as a means to an end – in this case, to satisfy board requirements – and to do so without patients’ explicit consent, violates the fundamental principle of respect for individuals.

I will not argue that resident surgery can be safely performed without risking harm to the patient. If the surgical instructor could exercise complete control over a procedure and correct any mistakes that the trainees made so that the procedure has the same outcome, then it would be ethically allowable. The surgical instructor must be confident that his residents are fully capable of performing the surgery on their own, otherwise it not ethical to subject the patient to this risk.

Dr. Ohye and I are both part of larger divisions that have their own obligations, and we have experience training residents at all levels. We have similar backgrounds, and we both benefited from having mentors who sometimes had masochistic patience in helping us get through surgeries that we probably weren’t ready for. I’m certain that those of us in academic medicine training programs believe that graduated involvement of trainees in patient care is an integral part of the surgical education process, and is critical to society as a whole.

However, the fact that patients may not directly benefit, and may actually be harmed, from the resident’s involvement in surgery creates an ethical dilemma. There is little literature to guide us through this dilemma. Professional societies only advise generally, noting that participation should be voluntary, without providing specifics. Regulatory boards simply set minimum requirements without providing guidance for the educational process. While the ACGME and the residency review committees oversee resident training, the responsibility for successful training is left largely to individual surgeons and individual programs. It’s only recently that the TSDA (Thoracic Surgery Directors Association) adopted the milestone concept that hopefully will help resolve some of these issues.

Consider a medium-sized program of around 300 patients: A difference of just one death, such as 10 or 11 per year, is the difference between being above or below the STS mean. Now that may not be statistically significant, but if you put that number on your website, it becomes important. It’s true that the practice of congenital heart surgery has changed over the last 15-20 years. Our program has seen resident cases roughly halved in the last 10 years. Most patients are operated on at a younger age, palliation is very rare. These are not meant to be excuses for not training residents – they’re just the reality.

The outcomes of surgeries are increasingly scrutinized by regulatory agencies and sources of public reporting. Competition between programs is intense. Patients, parents, and referring providers have become increasingly aware of outcomes to the point that it’s actually not unusual for a patient to ask “What’s your surgical site infection rate? What are the chances I’ll need to have a pacemaker? What are your individual results?” Insurance companies are starting to ask for financial data, economically profiling you to ensure that you’re being as efficient as possible. All of these things are contrary to our ability to train residents effectively.

Because of fear of taking too long or increasing complications, some surgeons say they are much more likely to accept residual defects when operating with trainees. It’s only with familiarity and time that the highly skilled attending and properly motivated resident may work in tandem and produce the best outcome – but not in the 10 cases the American Board of Thoracic Surgery requires.

Dr. Jaggers is the Barton-Elliman Chair in Pediatric Cardiothoracic Surgery at the University of Colorado and co–medical director of The Heart Institute at Children’s Hospital Colorado in Aurora. He argued against having residents perform surgery for board certification.

[email protected]

While stent placement has proved to be safe and effective for acute esophageal perforation, a head-to-head comparison with surgical repair has never been reported, so a team of investigators performed a small, single-system analysis that compared stenting and surgery and found that while both are equally effective, esophageal stent placement resulted in lower costs and lower morbidity rates.

Investigators led by Dr. Richard Freeman of St. Vincent Hospital in Indianapolis published their results in the June issue of the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.01.066]). Their study evaluated only 60 patients who had either stent placement or an operation for acute intrathoracic esophageal perforation between 2009 and 2012 within Ascension Health, a national Catholic-based network of 36 regional health systems; but the authors noted that they had extracted their data from the national Premier Inc. database, which covers 20% of U.S. hospital discharges, and used propensity matching to generate similar stent and surgical groups. Dr. Freeman presented the results at the annual meeting of the American Association of Thoracic Surgery in Toronto, April 28-30.

Courtesy of AATS

Patients who received stents had intensive care unit stays about half that of the surgery group – an average of 2 vs. 4 days. Likewise, their total hospital stays were about half: 6 days vs. 11 days for the surgery group. Complication rates were comparable: postrepair leaks were reported in 17% of the stent group and 20% who had surgery. While reoperation rates were significantly lower in the stent group (3% vs. 13%), four patients (13%) of the stent group did have stent migration. Morbidity was significantly higher in the surgery group (43% vs. 17%). While postprocedure leak rates were similar, those who had surgery were more likely to have reoperation for persistent leaks, the authors said.

Further, stent recipients were able to take nutrition by mouth earlier after surgery and had lower rates of needing enteral feeding at discharge – 17% vs. 60% for the surgery group. Dr. Freeman and his team also analyzed costs between the two procedures and found that total costs, including inpatient and outpatient costs, averaged $142,000 for surgery vs. $91,000 for stenting.

Because the incidence of esophageal perforation is so low, Dr. Freeman and his coauthors reported that performing a randomized trial comparing esophageal stenting and surgery has been difficult. The off-label nature of stenting for esophageal perforation has also complicated funding of a prospective trial. The study authors said a prospective, randomized design would have been preferable to the propensity-matched approach.

Surgery for esophageal tear has been around for almost 70 years with many improvements in technique, anesthesia, and antimicrobial therapy, but with a need for prolonged inpatient and outpatient care along with a postoperative leak rate as high as 39% (Ann. Thorac. Surg. 2010;90:1669-73). “A persistent leak following operative repair may also result in the need for esophageal diversion and subsequent reconstruction with its associated significant morbidity and patient dissatisfaction,” Dr. Freeman and his coauthors said.

The authors acknowledged shortcomings of their study included not accounting for how different stents used in the stenting group and individual surgeons and facilities may have influenced outcomes. Other shortcomings were that cost calculations may not have accounted for inflation or costs outside the Ascension Health system and the uniqueness of the procedure itself. “Lastly, the fact that both treatment strategies employed for iatrogenic esophageal perforation are likely uncommon procedures at most treatment facilities implies that standardization, even at the local level, may be lacking,” the authors stated.

The authors reported having no financial disclosures.

While stent placement has proved to be safe and effective for acute esophageal perforation, a head-to-head comparison with surgical repair has never been reported, so a team of investigators performed a small, single-system analysis that compared stenting and surgery and found that while both are equally effective, esophageal stent placement resulted in lower costs and lower morbidity rates.

Investigators led by Dr. Richard Freeman of St. Vincent Hospital in Indianapolis published their results in the June issue of the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.01.066]). Their study evaluated only 60 patients who had either stent placement or an operation for acute intrathoracic esophageal perforation between 2009 and 2012 within Ascension Health, a national Catholic-based network of 36 regional health systems; but the authors noted that they had extracted their data from the national Premier Inc. database, which covers 20% of U.S. hospital discharges, and used propensity matching to generate similar stent and surgical groups. Dr. Freeman presented the results at the annual meeting of the American Association of Thoracic Surgery in Toronto, April 28-30.

Courtesy of AATS

Patients who received stents had intensive care unit stays about half that of the surgery group – an average of 2 vs. 4 days. Likewise, their total hospital stays were about half: 6 days vs. 11 days for the surgery group. Complication rates were comparable: postrepair leaks were reported in 17% of the stent group and 20% who had surgery. While reoperation rates were significantly lower in the stent group (3% vs. 13%), four patients (13%) of the stent group did have stent migration. Morbidity was significantly higher in the surgery group (43% vs. 17%). While postprocedure leak rates were similar, those who had surgery were more likely to have reoperation for persistent leaks, the authors said.

Further, stent recipients were able to take nutrition by mouth earlier after surgery and had lower rates of needing enteral feeding at discharge – 17% vs. 60% for the surgery group. Dr. Freeman and his team also analyzed costs between the two procedures and found that total costs, including inpatient and outpatient costs, averaged $142,000 for surgery vs. $91,000 for stenting.

Because the incidence of esophageal perforation is so low, Dr. Freeman and his coauthors reported that performing a randomized trial comparing esophageal stenting and surgery has been difficult. The off-label nature of stenting for esophageal perforation has also complicated funding of a prospective trial. The study authors said a prospective, randomized design would have been preferable to the propensity-matched approach.

Surgery for esophageal tear has been around for almost 70 years with many improvements in technique, anesthesia, and antimicrobial therapy, but with a need for prolonged inpatient and outpatient care along with a postoperative leak rate as high as 39% (Ann. Thorac. Surg. 2010;90:1669-73). “A persistent leak following operative repair may also result in the need for esophageal diversion and subsequent reconstruction with its associated significant morbidity and patient dissatisfaction,” Dr. Freeman and his coauthors said.

The authors acknowledged shortcomings of their study included not accounting for how different stents used in the stenting group and individual surgeons and facilities may have influenced outcomes. Other shortcomings were that cost calculations may not have accounted for inflation or costs outside the Ascension Health system and the uniqueness of the procedure itself. “Lastly, the fact that both treatment strategies employed for iatrogenic esophageal perforation are likely uncommon procedures at most treatment facilities implies that standardization, even at the local level, may be lacking,” the authors stated.

The authors reported having no financial disclosures.

While stent placement has proved to be safe and effective for acute esophageal perforation, a head-to-head comparison with surgical repair has never been reported, so a team of investigators performed a small, single-system analysis that compared stenting and surgery and found that while both are equally effective, esophageal stent placement resulted in lower costs and lower morbidity rates.

Investigators led by Dr. Richard Freeman of St. Vincent Hospital in Indianapolis published their results in the June issue of the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.01.066]). Their study evaluated only 60 patients who had either stent placement or an operation for acute intrathoracic esophageal perforation between 2009 and 2012 within Ascension Health, a national Catholic-based network of 36 regional health systems; but the authors noted that they had extracted their data from the national Premier Inc. database, which covers 20% of U.S. hospital discharges, and used propensity matching to generate similar stent and surgical groups. Dr. Freeman presented the results at the annual meeting of the American Association of Thoracic Surgery in Toronto, April 28-30.

Courtesy of AATS

Patients who received stents had intensive care unit stays about half that of the surgery group – an average of 2 vs. 4 days. Likewise, their total hospital stays were about half: 6 days vs. 11 days for the surgery group. Complication rates were comparable: postrepair leaks were reported in 17% of the stent group and 20% who had surgery. While reoperation rates were significantly lower in the stent group (3% vs. 13%), four patients (13%) of the stent group did have stent migration. Morbidity was significantly higher in the surgery group (43% vs. 17%). While postprocedure leak rates were similar, those who had surgery were more likely to have reoperation for persistent leaks, the authors said.

Further, stent recipients were able to take nutrition by mouth earlier after surgery and had lower rates of needing enteral feeding at discharge – 17% vs. 60% for the surgery group. Dr. Freeman and his team also analyzed costs between the two procedures and found that total costs, including inpatient and outpatient costs, averaged $142,000 for surgery vs. $91,000 for stenting.

Because the incidence of esophageal perforation is so low, Dr. Freeman and his coauthors reported that performing a randomized trial comparing esophageal stenting and surgery has been difficult. The off-label nature of stenting for esophageal perforation has also complicated funding of a prospective trial. The study authors said a prospective, randomized design would have been preferable to the propensity-matched approach.

Surgery for esophageal tear has been around for almost 70 years with many improvements in technique, anesthesia, and antimicrobial therapy, but with a need for prolonged inpatient and outpatient care along with a postoperative leak rate as high as 39% (Ann. Thorac. Surg. 2010;90:1669-73). “A persistent leak following operative repair may also result in the need for esophageal diversion and subsequent reconstruction with its associated significant morbidity and patient dissatisfaction,” Dr. Freeman and his coauthors said.

The authors acknowledged shortcomings of their study included not accounting for how different stents used in the stenting group and individual surgeons and facilities may have influenced outcomes. Other shortcomings were that cost calculations may not have accounted for inflation or costs outside the Ascension Health system and the uniqueness of the procedure itself. “Lastly, the fact that both treatment strategies employed for iatrogenic esophageal perforation are likely uncommon procedures at most treatment facilities implies that standardization, even at the local level, may be lacking,” the authors stated.

The authors reported having no financial disclosures.

How patients with hypertrophic obstructive cardiomyopathy who have already undergone alcohol septal ablation fare after going on to have surgical septal myectomy has been a matter of speculation and conjecture among cardiac surgeons for years, so a team of investigators set out to evaluate the outcomes among those patients.

What they found was that patients with a history of alcohol septal ablation may have an increased risk of cardiac death and complications after they have transaortic septal myectomy later on instead of just having septal myectomy as the primary procedure. In the Journal of Thoracic and Cardiovascular Surgery, Dr. Eduard Quintana of the University of Barcelona and the Mayo Clinic in Rochester, Minn., and coauthors reported that their findings support the use of surgical septal myectomy as the preferred treatment for septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM) (J. Thorac. Cardiovasc. Surg. 2014 [doi:10.1016/j.jtcvs.2015.03.044]).

This small study evaluated 31 patients who had a failed alcohol septal ablation and then underwent septal myectomy and compared them to a group of 62 patients who had a septal myectomy only for HOCM. A total of 28 of the failed septal ablation patients had one such previous procedure and three had two or more percutaneous procedures before undergoing surgical septal myectomy. Study outcomes were cardiac death, advanced heart failure, and placement of an implantable cardioverter defibrillator (ICD). The study was conducted at the Mayo Clinic.

Percutaneous alcohol septal ablation utilizes injection of ethanol to correct left ventricular outflow tract obstruction (LVOT) in hypertrophic cardiomyopathy. Dr. Quintana and his coauthors reported that despite the percutaneous nature of alcohol septal ablation, its incidence of death and morbidity are not lower than surgical myectomy. They also reported that some countries are using alcohol ablation exclusively for septal reduction in HOCM. The rate of recurrence of severe symptoms after septal ablation is 20%, Dr. Quintana and his colleagues pointed out. “Thus, a sizeable proportion of patients having alcohol septal ablation may require transaortic septal myectomy for relief of LVOT, and outcome of such patients may be impaired,” they reported.

The 31 prior-ablation patients had a three times higher rate of implanted ICDs (32% vs. 11%), more arrhythmias (43% vs. 13% based on preoperative Holter monitoring), and a 12 times higher rate of postoperative complete heart block (19.4% vs. 1.6%). The prior–septal ablation group progressed to advanced heart failure at twice the rate, 22.5% at an average follow-up of 3.2 years, compared with about 10% in the primary septal myectomy group.

The authors also reported the 31 prior-ablation patients had significantly higher rates of interstitial and endocardial fibrosis – 70% vs. 26% and 87% vs. 67%, respectively.

“Our data contributes to accumulating evidence that the infarction induced by alcohol septal ablation may have adverse and unexpected consequences,” Dr. Quintana and his colleagues said.

However, the authors also acknowledged that one limit of their study was that it could not identify the overall failure rate of alcohol septal ablation among the larger patient population that underwent the procedure – “the inability to clearly define the denominator.” Nineteen of the 31 prior-ablation subjects had been referred from other institutions.

Coauthor Dr. Anna Sabata-Rotes received funding from Fundacia La Caxia, Barcelona. The other authors had no relationships to disclose.

How patients with hypertrophic obstructive cardiomyopathy who have already undergone alcohol septal ablation fare after going on to have surgical septal myectomy has been a matter of speculation and conjecture among cardiac surgeons for years, so a team of investigators set out to evaluate the outcomes among those patients.

What they found was that patients with a history of alcohol septal ablation may have an increased risk of cardiac death and complications after they have transaortic septal myectomy later on instead of just having septal myectomy as the primary procedure. In the Journal of Thoracic and Cardiovascular Surgery, Dr. Eduard Quintana of the University of Barcelona and the Mayo Clinic in Rochester, Minn., and coauthors reported that their findings support the use of surgical septal myectomy as the preferred treatment for septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM) (J. Thorac. Cardiovasc. Surg. 2014 [doi:10.1016/j.jtcvs.2015.03.044]).

This small study evaluated 31 patients who had a failed alcohol septal ablation and then underwent septal myectomy and compared them to a group of 62 patients who had a septal myectomy only for HOCM. A total of 28 of the failed septal ablation patients had one such previous procedure and three had two or more percutaneous procedures before undergoing surgical septal myectomy. Study outcomes were cardiac death, advanced heart failure, and placement of an implantable cardioverter defibrillator (ICD). The study was conducted at the Mayo Clinic.

Percutaneous alcohol septal ablation utilizes injection of ethanol to correct left ventricular outflow tract obstruction (LVOT) in hypertrophic cardiomyopathy. Dr. Quintana and his coauthors reported that despite the percutaneous nature of alcohol septal ablation, its incidence of death and morbidity are not lower than surgical myectomy. They also reported that some countries are using alcohol ablation exclusively for septal reduction in HOCM. The rate of recurrence of severe symptoms after septal ablation is 20%, Dr. Quintana and his colleagues pointed out. “Thus, a sizeable proportion of patients having alcohol septal ablation may require transaortic septal myectomy for relief of LVOT, and outcome of such patients may be impaired,” they reported.

The 31 prior-ablation patients had a three times higher rate of implanted ICDs (32% vs. 11%), more arrhythmias (43% vs. 13% based on preoperative Holter monitoring), and a 12 times higher rate of postoperative complete heart block (19.4% vs. 1.6%). The prior–septal ablation group progressed to advanced heart failure at twice the rate, 22.5% at an average follow-up of 3.2 years, compared with about 10% in the primary septal myectomy group.

The authors also reported the 31 prior-ablation patients had significantly higher rates of interstitial and endocardial fibrosis – 70% vs. 26% and 87% vs. 67%, respectively.

“Our data contributes to accumulating evidence that the infarction induced by alcohol septal ablation may have adverse and unexpected consequences,” Dr. Quintana and his colleagues said.

However, the authors also acknowledged that one limit of their study was that it could not identify the overall failure rate of alcohol septal ablation among the larger patient population that underwent the procedure – “the inability to clearly define the denominator.” Nineteen of the 31 prior-ablation subjects had been referred from other institutions.

Coauthor Dr. Anna Sabata-Rotes received funding from Fundacia La Caxia, Barcelona. The other authors had no relationships to disclose.

How patients with hypertrophic obstructive cardiomyopathy who have already undergone alcohol septal ablation fare after going on to have surgical septal myectomy has been a matter of speculation and conjecture among cardiac surgeons for years, so a team of investigators set out to evaluate the outcomes among those patients.

What they found was that patients with a history of alcohol septal ablation may have an increased risk of cardiac death and complications after they have transaortic septal myectomy later on instead of just having septal myectomy as the primary procedure. In the Journal of Thoracic and Cardiovascular Surgery, Dr. Eduard Quintana of the University of Barcelona and the Mayo Clinic in Rochester, Minn., and coauthors reported that their findings support the use of surgical septal myectomy as the preferred treatment for septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM) (J. Thorac. Cardiovasc. Surg. 2014 [doi:10.1016/j.jtcvs.2015.03.044]).

This small study evaluated 31 patients who had a failed alcohol septal ablation and then underwent septal myectomy and compared them to a group of 62 patients who had a septal myectomy only for HOCM. A total of 28 of the failed septal ablation patients had one such previous procedure and three had two or more percutaneous procedures before undergoing surgical septal myectomy. Study outcomes were cardiac death, advanced heart failure, and placement of an implantable cardioverter defibrillator (ICD). The study was conducted at the Mayo Clinic.

Percutaneous alcohol septal ablation utilizes injection of ethanol to correct left ventricular outflow tract obstruction (LVOT) in hypertrophic cardiomyopathy. Dr. Quintana and his coauthors reported that despite the percutaneous nature of alcohol septal ablation, its incidence of death and morbidity are not lower than surgical myectomy. They also reported that some countries are using alcohol ablation exclusively for septal reduction in HOCM. The rate of recurrence of severe symptoms after septal ablation is 20%, Dr. Quintana and his colleagues pointed out. “Thus, a sizeable proportion of patients having alcohol septal ablation may require transaortic septal myectomy for relief of LVOT, and outcome of such patients may be impaired,” they reported.

The 31 prior-ablation patients had a three times higher rate of implanted ICDs (32% vs. 11%), more arrhythmias (43% vs. 13% based on preoperative Holter monitoring), and a 12 times higher rate of postoperative complete heart block (19.4% vs. 1.6%). The prior–septal ablation group progressed to advanced heart failure at twice the rate, 22.5% at an average follow-up of 3.2 years, compared with about 10% in the primary septal myectomy group.

The authors also reported the 31 prior-ablation patients had significantly higher rates of interstitial and endocardial fibrosis – 70% vs. 26% and 87% vs. 67%, respectively.

“Our data contributes to accumulating evidence that the infarction induced by alcohol septal ablation may have adverse and unexpected consequences,” Dr. Quintana and his colleagues said.

However, the authors also acknowledged that one limit of their study was that it could not identify the overall failure rate of alcohol septal ablation among the larger patient population that underwent the procedure – “the inability to clearly define the denominator.” Nineteen of the 31 prior-ablation subjects had been referred from other institutions.

Coauthor Dr. Anna Sabata-Rotes received funding from Fundacia La Caxia, Barcelona. The other authors had no relationships to disclose.

Individuals with chronic ischemic mitral regurgitation who undergo mitral valve replacement show significantly superior exercise performance up to almost 3½ years after the operation when compared with those who have restrictive mitral valve annuloplasty, according to a study in the June issue of the Journal of Cardiovascular Surgery. (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.003]).

Doctors at three institutions in France, Italy, and the United Kingdom set out to predict what factors determined long-term functional capacity in patients with chronic ischemic mitral regurgitation (CIMR) who had either mitral valve replacement (MVR) or annuloplasty. They performed a retrospective analysis of 121 patients with significant chronic mitral regurgitation, 62 of whom had restrictive mitral valve annuloplasty and 59 of whom underwent MVR between 2005 and 2011. All the subjects had a resting echocardiography and a 6-minute treadmill test before their procedures and again at an average of 41 months afterwards. The MVR group walked an average of 37 meters farther at the postoperative stress test, whereas the annuloplasty patients walked on average 24 meters less than their preoperative test.

“The most important finding of this study is that, in patients with CIMR who underwent mitral valve surgery, the improvement in functional capacity at long-term follow-up is mainly related to the type of treatment and to the mitral valve hemodynamic performance, as expressed by changes in IEOA [indexed effective orifice area] during exercise,” reported lead author Dr. Carlo Fino of the Bristol (England) Heart Institute and Pope John XXIII Hospital in Bergamo, Italy, and his colleagues. Investigators from Hospital Dupuytren in Limoges, France, also participated.

The study noted inconclusive results of previous reports of patients treated for mitral regurgitation: the Cardiothoracic Surgical Trials Network study that showed similar 1-year outcomes among patients who had either MVR or annuloplasty (N. Engl. J. Med. 2014;370:23-32) ; an earlier study that showed annuloplasty patients may develop functional mitral stenosis with decreasing functional capacity (J. Am. Coll. Cardiol. 2008;51:1692-1701); and Dr. Fino and colleagues’ previous work that showed worse hemodynamics in annuloplasty patients, compared with MVR counterparts (J. Thorac. Cardiovasc. Surg. 2014;148:447-53).

Other comparative measures the latest study evaluated were: change in exercise indexed effective orifice area, increasing from 1.3 to 1.5 cm²/m² in the MVR group vs. 1.1 to 1.2 cm²/m² in the annuloplasty group; change in mean mitral gradients from rest to exercise, which increased significantly in both groups – from 4.3 to 9 mm Hg in the replacement group and 4.4 to 11 mm Hg in the annuloplasty group; postoperative cardiovascular events – 8% in the MVR group and 21% in the annuloplasty population; and follow-up survival – 88% for MVR vs. 83% for annuloplasty.

The annuloplasty patients received either a Carpentier-Edwards Physio ring (71%) or Carpentier-Edwards Classic ring (29%); Edwards Lifesciences. The MVR group received either a biological or mechanical prosthesis, although the study did not report how many of each. All patients had associated coronary bypass grafting surgery and all achieved complete revascularization. The MVR and annuloplasty groups were similar in terms of demographics and cardiac function, although a higher percentage of patients in the annuloplasty group had severe mitral regurgitation preoperatively – 41% vs. 32% in the MVR group.

Procedures like annuloplasty that aim to restore ventricular geometry or target the subvalvular mechanism “seem to be promising but they require further scientific evidence,” Dr. Fino and his coauthors said. They suggested that until 24-month results from the Cardiothoracic Surgical Trials Network are available, MVR with chordal sparing might be a “reliable option” for patients with chronic ischemic mitral regurgitation.

The authors had no disclosures.

Individuals with chronic ischemic mitral regurgitation who undergo mitral valve replacement show significantly superior exercise performance up to almost 3½ years after the operation when compared with those who have restrictive mitral valve annuloplasty, according to a study in the June issue of the Journal of Cardiovascular Surgery. (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.003]).

Doctors at three institutions in France, Italy, and the United Kingdom set out to predict what factors determined long-term functional capacity in patients with chronic ischemic mitral regurgitation (CIMR) who had either mitral valve replacement (MVR) or annuloplasty. They performed a retrospective analysis of 121 patients with significant chronic mitral regurgitation, 62 of whom had restrictive mitral valve annuloplasty and 59 of whom underwent MVR between 2005 and 2011. All the subjects had a resting echocardiography and a 6-minute treadmill test before their procedures and again at an average of 41 months afterwards. The MVR group walked an average of 37 meters farther at the postoperative stress test, whereas the annuloplasty patients walked on average 24 meters less than their preoperative test.

“The most important finding of this study is that, in patients with CIMR who underwent mitral valve surgery, the improvement in functional capacity at long-term follow-up is mainly related to the type of treatment and to the mitral valve hemodynamic performance, as expressed by changes in IEOA [indexed effective orifice area] during exercise,” reported lead author Dr. Carlo Fino of the Bristol (England) Heart Institute and Pope John XXIII Hospital in Bergamo, Italy, and his colleagues. Investigators from Hospital Dupuytren in Limoges, France, also participated.

The study noted inconclusive results of previous reports of patients treated for mitral regurgitation: the Cardiothoracic Surgical Trials Network study that showed similar 1-year outcomes among patients who had either MVR or annuloplasty (N. Engl. J. Med. 2014;370:23-32) ; an earlier study that showed annuloplasty patients may develop functional mitral stenosis with decreasing functional capacity (J. Am. Coll. Cardiol. 2008;51:1692-1701); and Dr. Fino and colleagues’ previous work that showed worse hemodynamics in annuloplasty patients, compared with MVR counterparts (J. Thorac. Cardiovasc. Surg. 2014;148:447-53).

Other comparative measures the latest study evaluated were: change in exercise indexed effective orifice area, increasing from 1.3 to 1.5 cm²/m² in the MVR group vs. 1.1 to 1.2 cm²/m² in the annuloplasty group; change in mean mitral gradients from rest to exercise, which increased significantly in both groups – from 4.3 to 9 mm Hg in the replacement group and 4.4 to 11 mm Hg in the annuloplasty group; postoperative cardiovascular events – 8% in the MVR group and 21% in the annuloplasty population; and follow-up survival – 88% for MVR vs. 83% for annuloplasty.

The annuloplasty patients received either a Carpentier-Edwards Physio ring (71%) or Carpentier-Edwards Classic ring (29%); Edwards Lifesciences. The MVR group received either a biological or mechanical prosthesis, although the study did not report how many of each. All patients had associated coronary bypass grafting surgery and all achieved complete revascularization. The MVR and annuloplasty groups were similar in terms of demographics and cardiac function, although a higher percentage of patients in the annuloplasty group had severe mitral regurgitation preoperatively – 41% vs. 32% in the MVR group.

Procedures like annuloplasty that aim to restore ventricular geometry or target the subvalvular mechanism “seem to be promising but they require further scientific evidence,” Dr. Fino and his coauthors said. They suggested that until 24-month results from the Cardiothoracic Surgical Trials Network are available, MVR with chordal sparing might be a “reliable option” for patients with chronic ischemic mitral regurgitation.

The authors had no disclosures.

Individuals with chronic ischemic mitral regurgitation who undergo mitral valve replacement show significantly superior exercise performance up to almost 3½ years after the operation when compared with those who have restrictive mitral valve annuloplasty, according to a study in the June issue of the Journal of Cardiovascular Surgery. (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.003]).

Doctors at three institutions in France, Italy, and the United Kingdom set out to predict what factors determined long-term functional capacity in patients with chronic ischemic mitral regurgitation (CIMR) who had either mitral valve replacement (MVR) or annuloplasty. They performed a retrospective analysis of 121 patients with significant chronic mitral regurgitation, 62 of whom had restrictive mitral valve annuloplasty and 59 of whom underwent MVR between 2005 and 2011. All the subjects had a resting echocardiography and a 6-minute treadmill test before their procedures and again at an average of 41 months afterwards. The MVR group walked an average of 37 meters farther at the postoperative stress test, whereas the annuloplasty patients walked on average 24 meters less than their preoperative test.

“The most important finding of this study is that, in patients with CIMR who underwent mitral valve surgery, the improvement in functional capacity at long-term follow-up is mainly related to the type of treatment and to the mitral valve hemodynamic performance, as expressed by changes in IEOA [indexed effective orifice area] during exercise,” reported lead author Dr. Carlo Fino of the Bristol (England) Heart Institute and Pope John XXIII Hospital in Bergamo, Italy, and his colleagues. Investigators from Hospital Dupuytren in Limoges, France, also participated.

The study noted inconclusive results of previous reports of patients treated for mitral regurgitation: the Cardiothoracic Surgical Trials Network study that showed similar 1-year outcomes among patients who had either MVR or annuloplasty (N. Engl. J. Med. 2014;370:23-32) ; an earlier study that showed annuloplasty patients may develop functional mitral stenosis with decreasing functional capacity (J. Am. Coll. Cardiol. 2008;51:1692-1701); and Dr. Fino and colleagues’ previous work that showed worse hemodynamics in annuloplasty patients, compared with MVR counterparts (J. Thorac. Cardiovasc. Surg. 2014;148:447-53).

Other comparative measures the latest study evaluated were: change in exercise indexed effective orifice area, increasing from 1.3 to 1.5 cm²/m² in the MVR group vs. 1.1 to 1.2 cm²/m² in the annuloplasty group; change in mean mitral gradients from rest to exercise, which increased significantly in both groups – from 4.3 to 9 mm Hg in the replacement group and 4.4 to 11 mm Hg in the annuloplasty group; postoperative cardiovascular events – 8% in the MVR group and 21% in the annuloplasty population; and follow-up survival – 88% for MVR vs. 83% for annuloplasty.

The annuloplasty patients received either a Carpentier-Edwards Physio ring (71%) or Carpentier-Edwards Classic ring (29%); Edwards Lifesciences. The MVR group received either a biological or mechanical prosthesis, although the study did not report how many of each. All patients had associated coronary bypass grafting surgery and all achieved complete revascularization. The MVR and annuloplasty groups were similar in terms of demographics and cardiac function, although a higher percentage of patients in the annuloplasty group had severe mitral regurgitation preoperatively – 41% vs. 32% in the MVR group.

Procedures like annuloplasty that aim to restore ventricular geometry or target the subvalvular mechanism “seem to be promising but they require further scientific evidence,” Dr. Fino and his coauthors said. They suggested that until 24-month results from the Cardiothoracic Surgical Trials Network are available, MVR with chordal sparing might be a “reliable option” for patients with chronic ischemic mitral regurgitation.

The authors had no disclosures.