SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization in the FREEDOM Trial

https://www.sciencedirect.com/science/article/pii/S073510971838690X?via%3Dihub


The FREEDOM trial
A multicenter trial that studied diabetic patients with multivessel native CAD without left main stenosis or chronic total occlusions that had an indication for myocardial revascularization and were candidates for either CABG or PCI. Patients were randomized to either CABG or PCI with drug-eluting stents.

They used HCE, not MACCE.
Hard cardiovascular events
Death from any cause, nonfatal MI, and nonfatal stroke.

SS is useful for PCI not CABG.

Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction
Circ J 2019; 83: 122–129

https://www.jstage.jst.go.jp/article/circj/83/1/83_CJ-18-0653/_pdf/-char/en

The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear.

111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG:
 63 underwent CR
 48 underwent incomplete revascularization (IR).

At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and MACCE were significantly greater in the IR group.

After adjusting for propensity score,
NO! significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75–2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68–3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08–3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34–11.44; P=0.013).

Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.


Does the Cardiac Surgeon Accept Coronary Artery Bypass  Grafting With Incomplete Revascularization for Patients  With Low Ventricular Function and Complex  Multivessel Coronary Disease?

Prosthesis–Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement

Prosthesis–Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement


http://www.onlinejacc.org/content/72/22/2701


On the basis of the discharge echocardiographic effective valve area indexed to body surface area, PPM was classified as severe (<0 .65="" 0.85="" cm2="" m2="" moderate="" none="" or="" to="">0.85 cm2/m2). 

Severe and moderate PPM were present following TAVR in 12% and 25% of patients, respectively.

Severe PPM after TAVR was present in 12% of patients and was associated with higher mortality and HF rehospitalization at 1 year.



Generally, PPM after SAVR doesn't matter. Moreover, PPM might be thought as old fashion in new prosthetic aortic valve (Crown and Trifecta) era.
It seems that severe PPM after SAVR and TAVI is quite different.
It might be reason why the incidence of severe PPM after TAVI is generally less than SAVR.

Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease

Functional Mitral Regurgitation: Therapeutic Strategies for a Ventricular Disease
J Cardiac Fail 2014;20:252 -267


ABSTRACT
Functional mitral regurgitation is a highly prevalent condition among patients with ischemic and dilated cardiomyopathies. Arising from remodeling of both the mitral valve annulus and the left ventricle, it is associated with high mortality and morbidity. In selected patients, cardiac resynchronization therapy helps to reduce functional mitral regurgitation, but surgical intervention remains the mainstay of therapy when medical therapy for left ventricular dysfunction has been inadequate. It is, however, associated with significant perioperative risks and does not alter long-term mortality. Percutaneous devices, and more recently the Mitraclip in particular, represent a promising alternative that can improve symptoms and ventricular remodeling with significantly lower periprocedural risk.



It remains unclear whether fMR repair is beneficial to this ventricular-valvular disease paradigm.
Current ACC/AHA and ESC guidelines do not make a distinction in recommended diagnostic modalities or in classification schema for severity, between fMR and
other etiologies of MR.
Medical therapy is limited in its ability to fully correct fMR.
CRT specifically targets myocardial dyssynchrony, which can be especially pronounced in those patients with segmental wall motion abnormalities and contributes to fMR.
MV surgery significantly reduces or eliminates fMR, reduces LV dimensions, and improves symptoms, but it is also associated with periprocedural complications,
such as mortality, bleeding, stroke, and renal dysfunction, and provides no clear long-term mortality benefit. There have been no randomized trials to compare the effectiveness of different surgical repair techniques.
Although there have been no prospective studies comparing the effects of MV surgery alone with the combination procedure of valve surgery and SVR, the combination procedure allowed for more consistent reduction in fMR but not
mortality, and they are accompanied by high perioperative risk.
Edge-to-Edge Repair (Mitraclip) corrects fMR with significantly lower periprocedural risk.

Pulmonary Hypertension

Pulmonary Hypertension

Two blood flow patterns of PH with different prognoses have been reported in patients with heart failure. In the most common, called post-capillary PH (IpcPH), PH is solely caused by increased left-sided filling pressures. However, 10-15% of patients have both pre- and post-capillary PH (CpcPH), characterized by high filling pressures and a pulmonary vascular component.

This form of PH has similarities with pulmonary arterial hypertension, and is defined by a combined elevation of mean pulmonary artery wedge pressure (mPAWP), a measure of pressure in the upper left heart chamber, or atrium; pulmonary vascular resistance (PVR), reflecting changes in arteries that supply blood to the lungs; and/or diastolic pressure gradient (DPG), which is the difference between pulmonary artery diastolic pressure and mean pulmonary capillary wedge pressure.


Old
Transpulmonary pressure gradient（TPG：mean PAP － mean PAWP)
12<  CpcPH,  12>  IpcPH

New
Diastolic pressure gradient (DPG : diastolic PAP - mean PAWP)
7<  CpcPH,  7>  IpcPH

PVR ＞ 3.0 Wood CpcPH, PVR ≦ 3.0 Wood  IpcPH


Prognosis
CpcPH BAD
IpcPH better

Cost-Effectiveness of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis at Intermediate Risk: Results From the PARTNER 2 Trial

https://www.ctsnet.org/jans/cost-effectiveness-transcatheter-versus-surgical-aortic-valve-replacement-patients-severe?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F21%2F2018


Cost-effective analysis of TAVR versus SAVR in 3110 intermediate-risk aortic stenosis patients from the PARTNER-2 trial

Costs were ~$20,000 higher with TAVR than SAVR.
Total cost differences for the index hospitalization were
only $2888 higher with XT-TAVR (p=0.014) and
$4155 lower with S3-TAVR (p<0 .001="" nbsp="" p="">owing to reductions in length of stay with TAVR.

Follow-up costs were significantly lower with XT-TAVR (△-$9304; p<0 .001="" and="" compared="" nbsp="" p="" s3-tavr="" savr.="" with="">
Over a lifetime horizon, TAVR was projected to lower total costs by $8000-$10,000 and to increase quality-adjusted survival by 0.15-0.27 years.

 XT-TAVR and S3-TAVR were found to be economically dominant compared with SAVR in 84% and 97% of bootstrap replicates, respectively.


Q
TAVR Durability is same as SAVR? We'll see.
If the durability of TAVR is inferior, the results might be changed.

“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair

“Respect When You Can, Resect When You Should”: A Realistic Approach to Posterior Leaflet Mitral Valve Repair

https://www.ctsnet.org/jans/%E2%80%9Crespect-when-you-can-resect-when-you-should%E2%80%9D-realistic-approach-posterior-leaflet-mitral-valve?utm_source=iContact&utm_medium=email&utm_campaign=ctsnet&utm_content=JANS+12%2F7%2F2018

J Thorac Cardiovasc Surg　2018;156:1856-66

“respect when you can, resect when you should” concept
 Resection was performed only if an excess tissue in height or width was present. The excess tissue in height was treated if P2, after a complete unfolding, was twice as high than P1 or P3. In such cases, a transverse resection of P2 was performed to bring it to approximately the same height as P1 and P3 (P2 being slightly higher than P1 and P3 in a normal valve).
This usually removes the rough area that was thickened. During this
operative step, great care was taken to individualize the secondary, and
even marginal, chordae that were at the adequate length (when compared
with the reference point) to resuspend the new free edge of P2. As far as
the excess in width is concerned, it was treated and carried out each time
there was an obvious and natural transverse folding of the leaflet. The
most objective way to evaluate such an excess of tissue in width was to
lay P2 on the posterior ventricular wall and to see if there was any natural
folding. When this happened, a small triangular resection was performed,
the base of the triangle being at the level of the free edge and the apex at the
annulus. A small resection was often effective in eliminating the excess
transverse tissue without putting the posterior leaflet (PL) under tension

2005 - 2015
701 consecutive  severe mitral regurgitation
441 degenerative:  376 posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments)

aged 65.8 ± 13 years, and 70.5% were male.
Median follow-up was 61.1 months.

There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%).

After 1, 5, and 10 years,
overall survival was 97.8%, 93.6%, and 86.7%
recurrent/residual >2+ mitral regurgitation was  0.7%, 1.9%, and 5.9%
New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.