Search

OBJECTIVES: Two trials (COAPT and MITRA-FR) were published in 2018 evaluating the effectiveness and safety of transcatheter repair for heart failure patients with significant functional MR, which yielded different results. This paper reviews the strength of the evidence, differences in trial designs, ethical and implementation implications, and delineates future research needs to help guide the appropriate dissemination of transcatheter repair for functional MR patients. METHODS: The National Heart, Lung and Blood Institute convened a workshop of interdisciplinary experts to address these objectives. RESULTS: Transcatheter repair of functional MR can provide significant benefits in terms of heart failure hospitalizations, survival and quality-of-life, when appropriate heart failure candidates, with moderate to severe or severe MR while on optimal guideline-directed medical therapy, can be identified. Key ingredients for success are pre-operative evaluation and management and post-operative care by an interdisciplinary heart team. CONCLUSIONS: Given the discordance observed between trials, ongoing innovation in patient management and potential expansion of indications for use, the evidence base must be expanded to optimize appropriate implementation of this complex therapy. This will require more complete capture of outcome data in real-world settings for all eligible candidates, whether or not they receive this therapy. Inevitably, the indications for use of this therapy will expand, as will the devices and therapeutic approaches for this population, necessitating the study of comparative effectiveness through randomized trials or observational studies. Moreover, given the substantial variations in care delivery, conducting implementation research to delineate characteristics of the optimal care model would be of benefit.

Objective The aim of this paper is to report midterm results of thoracic endovascular aortic repair (TEVAR) for ascending aortic pseudoaneurysms (AAPs) and penetrating aortic ulcers (PAUs) of the ascending aorta. Methods This study was retrospective and performed at tertiary centers. Eight patients with AAPs (n = 5) and PAUs (n = 3) received total endovascular repair of the ascending aorta. Patients with a history of type A aortic dissection or fusiform aneurysm were excluded. All patients analyzed were considered to be at high risk for open repair at the time of presentation. Results Urgent intervention was performed in 6 (75%) cases. Primary clinical success was achieved in 7 (87.5%) cases. A low-flow type 3 endoleak remained asymptomatic and was managed conservatively. No TEVAR-related in-hospital mortality, primary conversion, cerebrovascular accidents, valve impairment, or myocardial infarction occurred. All patients were discharged home, alive and independent, after a median length of stay of 6 (range: 5-24) days. No patient was lost at a mean follow-up of 40 ± 33 (range: 4-93) months. Ongoing primary clinical success was maintained in all but 1 patient (type 3 endoleak): aortically related reintervention was never required. No endograft breakage or migration was observed. At 1-year follow-up, 7 (87.5%) aortic lesions had significant reduction in diameter (≥5 mm). Conclusions Ascending TEVAR was feasible, safe, and effective for AAPs and PAUs. In a very select subset of lesions, midterm results were favorable, with both standard and custom-designed endografts.

This commentary discusses the observational paper by Benedetto and colleagues, which investigates multi-arterial vs. single arterial grafting and on- vs. off –pump coronary artery bypass surgery.

Since the introduction of the tumor, node, and metastasis (TNM) classification of malignant tumors in 1943, there have been periodic revisions updating the classifications of the different tumors. The most recent revision for lung cancer appeared in the seventh edition of the TNM classification of malignant tumors, published by the Union for International Cancer Control, the American Joint Committee on Cancer, and the International Association for the Study of Lung Cancer. Among other innovations, pleural dissemination (malignant pleural effusion and malignant pleural nodules) was upstaged from the previous T4 category to the new M1a category. However, cancer cells can be present in the pleural cavity with no pleural effusion. This finding can be the result of exfoliation from lung cancer or surgical manipulation in operated patients, but its significance is not clear. Pleural lavage cytology (PLC) provides a cytologic diagnosis at the time of surgery, but the result of PLC is not included as a descriptor in the seventh edition of the TNM classification and staging system. Some studies suggest that a positive PLC is an independent prognostic factor and a predictor of tumor recurrence, but others do not support the value of pleural lavage. The International Pleural Lavage Cytology Collaborators recommended that a single increase in the T category up to a maximum of T4 be assigned to patients with positive PLC results. In the original paper published in this issue, Kameyama and colleagues studied a retrospective series of 11,073 patients operated on for non–small cell lung cancer in 2004 and followed up for more than 5 years. Of these, 4171 underwent PLC and in 217 (5.2%) it was positive. The

In 1971, 1,2 the future of patients with chronically elevated venous pressures was unknown, but the intriguing physiology of total right heart bypass was demonstrated to be compatible with life. In 1975, in Toronto, I presented “Recent Surgical Approach to Tricuspid Atresia,” the international experience of 35 patients with 10 hospital and 2 late deaths. After 32 years, my colleagues and I reviewed the outcome of that original cohort of patients. From communications with the pioneer cardiothoracic centers (Bordeaux, Mayo Clinic, and Chicago) included in that original paper, we learned that only 1 patient is still alive of the 23 survivors treated before 1975: that survivor is the fifth patient on which we operated, as presented in Toronto. The aim of this article is (1) to review the follow-up of our 5 survivors, (2) to explore the lessons learned over the years, and (3) to present a survival with total right heart bypass for more than 32 years, to my knowledge the longest in the world.