Surveying the Literature: Synopsis of Recent Key Publications

1. ANESTHESIA MANAGEMENT DURING TRANSCATHETER AORTIC VALVE REPLACEMENT Hyman MC, Vemulapalli S, Szeto WY, et al. Conscious sedation versus general anesthesia for transcatheter aortic valve replacement: insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circulation. 2017;136:2132–2140. Conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) is increasingly common, but questions remain about its benefits and risks. To provide contemporary insights, Hyman et al analyzed existing data from a large US registry between April 2014 and June 2015. CS was used in 15.8% of 10,997 cases of transfemoral TAVR. After propensity score adjustment, compared to general anesthesia (GA), CS was associated with a lower procedural success (97.9% vs 98.6%) but a reduced in-hospital and 30-day mortality (1.5% vs 2.4% and 2.3% vs 4.0%, respectively), less use of intraprocedural inotropes (29.3% vs 43.7%), shorter hospital stay (6.0 vs 6.5 days), and more likely discharge to home (77.0% vs 74.4%). The percentage of cases performed with CS increased from 11% to 20% during the study period, and the incidence of conversion from CS to GA was 5.9%. 2. RESTRICTIVE RED-CELL TRANSFUSION STRATEGY FOR CARDIAC SURGERY Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017;377:2133–2144. While a restrictive red-cell–transfusing strategy is widely accepted in many clinical circumstances, its safety in patients undergoing cardiac surgery is unclear. Mazer et al report this prospective, randomized, multicenter (73), international (19 countries) Transfusion Requirements In Cardiac Surgery III trial of 5243 moderate- to high-risk (European System for Cardiac Operative Risk Evaluation [EuroSCORE] score ≥6) adults undergoing cardiac surgery with cardiopulmonary bypass (26% coronary artery bypass grafting [CABG] only, 28% CABG plus other, and 46% other). The restrictive group received 1 unit of red-cells for hemoglobin (Hgb) <7.5 g/dL, whereas the liberal group received 1 unit of red-cells for Hgb <9.5 g/dL, intraoperatively or postoperatively. The incidence of the composite outcome (death, nonfatal myocardial infarction, stroke, or new dialysis) (11.4% vs 12.5%) and any of its components were not different with the restrictive strategy. However, the risk of the composite outcome was lower in patients ≥75 years of age (adjusted odds ratio, 0.70). 3. WAIT TIME AND MORTALITY AFTER HIP FRACTURE SURGERY Pincus D, Ravi B, Wasserstein D, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318:1994–2003. How long it is safe to wait to perform hip fracture surgery is controversial. Using risk-adjusted restricted cubic splines modeling, Pincus et al determined the inflection point in hours when 30-day mortality and complications increased in more than 42,000 hip fracture patients (mean age, 80 years; 70.5% women), many of whom had operative risk factors (~76% hypertension, ~27% diabetes, ~28% dementia), across 72 hospitals in Ontario, Canada. Mean time to surgery was 39 hours, and overall 30-day mortality was 7%. Risk of mortality and complications began to increase at 24 hours. Nearly 14,000 propensity score--matched patients operated >24 hours, compared with a similar number operated within 24 hours, had a higher 30-day mortality (6.5% vs 5.8%) and composite adverse outcome of mortality and complications (12.2% vs 10.1%). The accompanying thoughtful editorial by Vrahas and Sax (JAMA. 2017;318:1981–1982) identifies impediments to prompt surgery in these patients and suggests a method to facilitate achieving the goal of earlier surgery. 4. FIVE-YEAR OUTCOME OF PATIENTS WITH HEART FAILURE Shah KS, Xu H, Matsouaka RA, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. J Am Coll Cardiol. 2017 [Epub ahead of print]. Doi: 10.1016/j.jacc.2017.08.074. This study documents the devastatingly high 5-year mortality of patients discharged after hospitalization for acute heart failure, which appears the same regardless of having a preserved or reduced left ventricular (LV) ejection fraction (EF). Shah et al analyzed the follow-up of nearly 40,000 patients, ≥65 years of age (mean age, 80 years), in the American Heart Association Get With The Guidelines–Heart Failure registry, discharged between 2005 and 2009. Forty-six percent had preserved EF (≥50%; mean, 60%), 46% reduced EF (≤40%; mean, 28%), and 8% borderline EF (41%–49%; mean, 45%). The mean 5-year mortality was 75%, and was similar in all 3 groups; median survival was 2.1 years, and declined with initial age (being ≤4 years in patients 65–69 years of age at initial hospitalization, and ~1 year in patients ≥90 years of age), which was about one-fifth the survival rate in the general population for those age groups. These findings indicate the need to develop new therapeutic strategies for patients with heart failure, while also informing current surgical and anesthesia decision-making. 5. TEN-YEAR MORTALITY AFTER OFF-PUMP VERSUS ON-PUMP CABG Takagi H, Ando T, Mitta S; ALICE (All-Literature Investigation of Cardiovascular Evidence) Group. Meta-analysis comparing ≥10-year mortality of off-pump versus on-pump coronary artery bypass grafting. Am J Cardiol. 2017;120:1933–1938. These authors conducted a meta-analysis of 16 propensity score--matched observational studies with ≥10-year follow-up of more than 82,000 patients, comparing off-pump and on-pump CABG. They observed an increased mortality in the off-pump patients (hazard ratio, 1.07). This concurs with the finding in 18 randomized controlled trials (RCTs) with ≥1-year follow-up, 7 such trials with ≥3-year follow-up, and a meta-analysis of 5 RCTs and 17 observational trials with ≥5-year follow-up. The authors posit that the increased mortality may result from less complete revascularization, fewer distal anastomoses, and worse graft patency. 6. PREDICTING RISK IN GERIATRIC PATIENTS Min L, Hall K, Finlayson E, et al. Estimating risk of postsurgical general and geriatric complications using the VESPA preoperative tool. JAMA Surg. 2017;152:1126–1133. A group at the University of Michigan has developed a preoperative Vulnerable Elders Surgical Pathways and Outcome Assessment (VESPA) tool that can be administered in <10 minutes by surgical physician assistants to predict surgical and geriatric (eg, delirium, pressure ulcers, falls, and malnutrition) complications. Min et al report the application of the VESPA tool in 736 patients ≥70 years of age (mean ≈ 78). Eighteen percent experienced geriatric complications, and 15% surgical complications. An abbreviated VESPA scale was found to have a specificity of 76%, a sensitivity of 68%, and an area under the receiver-operator curve of 0.76 in predicting surgical and geriatric complications. 7. POSTOPERATIVE DELIRIUM AND 5-YEAR MORTALITY Moskowitz EE, Overbey DM, Jones TS, et al. Postoperativedelirium is associated with increased 5-year mortality. Am J Surg. 2017;214:1036–1038. Short-term adverse effects of postoperative delirium (POD) are well documented, but long-term effects are less clear. In this single-institution (Denver Veterans Affairs Medical Center) prospective study of 172 patients ≥50 years of age (mean age, 64) undergoing elective major operations with planned intensive care unit (ICU) admission, 44% experienced POD. The 5-year mortality was higher in these patients (59% vs 13%). A multivariable regression model for 5-year mortality identified POD as an independent factor associated with 5-year mortality, with an adjusted odds ratio of 7.35. 8. IMPACT OF FRAILTY ON FUNCTIONAL SURVIVAL 1YEAR AFTERCARDIAC SURGERY Lytwyn J, Stammers AN, Kehler DS, et al. The impact of frailty on functional survival in patients 1 year after cardiac surgery. J Thorac Cardiovasc Surg. 2017;154:1990–1999. Maintaining or improving the health-related quality of life (HRQoL) is of equal importance to patients as survival. Frailty is common in elderly and impacts outcome. However, common assessment tools for cardiac operative risk do not include frailty, and standard outcomes have not included functional survival. This prospective, single-center study sought to assess the impact of preoperative frailty on 1-year functional survival (alive with a EuroQol visual analog score ≥60) in 188 patients undergoing a variety of cardiac surgical procedures, with a median age of 71 years (range, 66–76) and a mean EuroSCORE II of 1.6. Using 3 different commonly used frailty criteria/scales, between 32% and 53% of patients were identified as being frail preoperatively. After adjustment for EuroSCORE II, the presence of preoperative frailty was associated with a 2- to 3.5-fold greater risk of poor functional survival 1 year after cardiac surgery. OTHER ARTICLES OF POSSIBLE INTEREST 1. Anesthetics and Cognitive Impairments in Developing Children: What Is Our Responsibility? Jevtovic-Todorovic V. JAMA Pediatr. 2017;171:1135–1136. 2. Apneic Oxygen Insufflation Decreases the Incidence of Hypoxemia During One-Lung Ventilation Jung DM, Ahn HJ, Jung SH, et al. J Thorac Cardiovasc Surg. 2017;154:360–366. 3. Is Medical Education a Public or a Private Good? Lucey CR. JAMA. 2017;318:2303–2305. 4. Predictors of Operating Room Extubation in Adult Cardiac Surgery Subramaniam K, DeAndrade DS, Mandell DR, et al. J Thorac Cardiovasc Surg. 2017;154:1656–1665. 5. Coffee Consumption and Health Poole R, Kennedy OJ, Roderick P, et al. BMJ. 2017;359:j5024. 6. Type 1 and 2 Myocardial Infarction and Myocardial Injury: Clinical Transition to High-Sensitivity Cardiac Troponin I Sandoval Y, Smith SW, Sexter A, et al. Am J Med. 2017;130:1431–1439. 7. Diagnostic Testing for Obstructive Sleep Apnea in Adults Mokhlesi B, Cifu AS. JAMA. 2017;318:2035–2036. 8. Optimal Blood Pressure During Cardiopulmonary Bypass Hori D, Nomura Y, Ono M, et al. J Thorac Cardiovasc Surg. 2017;154:1590–1598. 9. Dementia Prevention, Intervention, and Care Livingston G, Sommerlad A, Orgeta V, et al. Lancet. 2017;390:2673–2734. DISCLOSURES Name: Eugene A. Hessel, II, MD. Contribution: This author wrote the manuscript. This manuscript was handled by: Thomas R. Vetter, MD, MPH.

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