Surgery for Aortic Dilatation in Patients With Bicuspid Aortic Valves: A Statement of Clarification From the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: the "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease" (Circulation. 2010;121:e266-e369) and the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" (Circulation. 2014;129:e521-e643). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline.

Ascending Aortic Aneurysms <4.5 cm for Nonsyndromic Adults: Very Slow Growth and Low Risk.

BACKGROUND: Current practice guidelines for patients with thoracic aortic aneurysms (TAAs) recommend 6 to 12-month intervals for surveillance imaging based on growth estimates of 0.10 to 0.42 cm/y gleaned from limited studies which included patients with thoracoabdominal aneurysms, known acute or chronic aortic dissection, and other syndromic and nonsyndromic high-risk conditions (TAA-HRC) associated with high-risk for adverse aortic events and death. Our objective was to determine TAA growth and event-free survival rates for patients with aortic root or midascending diameters <5.0 cm, and without thoracoabdominal aneurysms, acute or chronic aortic dissection or higher risk syndromic or nonsyndromic conditions (TAA-NoHRC). METHODS: A retrospective review of patient records and imaging studies were done. Aortic diameter measurements were all performed by the lead author. RESULTS: For 197 TAA-NoHRC found incidentally during chest imaging, with 616 chest imaging studies over 868 patient-years, the mean aortic root and midascending aortic growth rates were 0.018 and 0.022 cm/y, respectively. The growth rate was significantly lower for aneurysms initially measured at <4.5 cm versus ≥ 4.5 cm at both the aortic root (0.011 vs. 0.068 cm/y) and midascending aorta (0.013 vs. 0.043 cm/y). Survival free from adverse aortic events (dissection, rupture, and surgery) or death at 5 years was 99.5%. CONCLUSION: Adult TAA-NoHRC patients with initial aortic root and/or ascending aortic diameters <5.0 cm, and particularly <4.5 cm, have very low aortic growth, and adverse event rates which may permit longer intervals between surveillance imaging, up to 3 to 5 years, after initial (6-12 months) stability is documented.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Aprotinin does not increase the risk of renal failure in cardiac surgery patients.

BACKGROUND: Aprotinin is frequently used in high-risk cardiac surgery patients to decrease bleeding complications and transfusions of packed red blood cells (PRBC). Transfusions of PRBC are known to directly increase the risk of new onset postoperative renal failure (ARF) in cardiac surgery patients. A recent highly publicized report implicated aprotinin as an independent causal factor for postoperative renal failure, but ignored the potential confounding affect of numerical PRBC data on ARF. We sought to investigate that claim with an analysis that included all perioperative risk factors for renal failure, including PRBC transfusion data. METHODS AND RESULTS: Prospectively collected patient data from 12 centers contributing to the Merged Cardiac Registry, an international multicenter cardiac surgery database, operated on between January 2000 and February 2006 were retrospectively analyzed. A previously published risk model for ARF incorporating 12 variables was used to calculate a baseline ARF risk score for each patient in whom those variables were available (n=15,174). After adding transfused PRBC data 11,198 patients remained for risk-adjusted assessment of ARF in relation to aprotinin use. Risk-adjusted multivariable analyses were carried out with, and without, consideration of transfused PRBC. Aprotinin was used in 24.6% (2757/11,198). The overall incidence of ARF was 1.6% (180/11,198) and was higher in the aprotinin subset (2.6%, 72/2757 versus 1.3%, 108/8441; P<0.001). The incidence of ARF directly and significantly increased with increasing transfusions of PRBC (P<0.001). Risk-adjusted analysis without transfused PRBC in the model suggests that aprotinin significantly impacts ARF (P=0.008; OR=1.5). However, further risk adjustment with the addition of the highly significant transfused PRBC variable (P<0.0001; OR=1.23/transfused PRBC) to the model attenuates the purported independent affect of aprotinin (P=0.231) on ARF. CONCLUSIONS: The increase in renal failure seen in patients who were administered aprotinin was directly related to increased number of transfusions in that high-risk patient population. Aprotinin use does not independently increase the risk of renal failure in cardiac surgery patients.

Atherosclerosis secondary prevention performance measures after coronary bypass graft surgery compared with percutaneous catheter intervention and nonintervention patients in the Get With the Guidelines database.

BACKGROUND: The American Heart Association Get With the Guidelines-Coronary Artery Disease program facilitates patient and physician compliance with proven atherosclerosis risk reduction strategies with collaborative learning sessions, teaching materials, predischarge online check lists, and web-based performance measure feedback for continuous quality improvement. Patients having coronary artery bypass graft surgery (CABG) may be subject to different care processes, nursing unit pathways, and personnel than patients having percutaneous catheter intervention or neither intervention, which may affect compliance. METHODS AND RESULTS: The Get With the Guidelines-Coronary Artery Disease database was queried to determine whether compliance with secondary prevention performance measures for CABG patients was different from that for nonsurgical patients. A total of 119,106 patients were treated with CABG (14,118), percutaneous catheter intervention (58,702), or neither intervention (46,286). Compliance with medication prescriptions, including aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering drugs, and smoking cessation counseling for eligible patients was analyzed. Medically appropriate exclusions and contraindications were included in the analysis. After adjusting for 14 clinical variables, CABG patients were less likely to receive most secondary prevention measures relative to percutaneous catheter intervention patients. In contrast, CABG patients were more likely to receive aspirin, beta-blocker, and smoking cessation counseling than neither intervention patients. Composite adherence and defect-free rates were highest for percutaneous catheter intervention patients and lowest for neither intervention patients after adjustment. CONCLUSIONS: There are significant differences in compliance at hospital discharge with secondary prevention performance measures for CABG patients compared with nonsurgical patients. Process of care differences may explain these differences and should be examined further because significant opportunities for improved compliance are evident. CABG patients in particular represent a group for whom secondary prevention has proven benefits, and they may benefit from future quality improvement interventions.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography. A report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Cardiovascular Health in Turner Syndrome: A Scientific Statement From the American Heart Association.

Girls and women with Turner syndrome face a lifelong struggle with both congenital heart disease and acquired cardiovascular conditions. Bicuspid aortic valve is common, and many have left-sided heart obstructive disease of varying severity, from hypoplastic left-sided heart syndrome to minimal aortic stenosis or coarctation of the aorta. Significant enlargement of the thoracic aorta may progress to catastrophic aortic dissection and rupture. It is becoming increasingly apparent that a variety of other cardiovascular conditions, including early-onset hypertension, ischemic heart disease, and stroke, are the major factors reducing the life span of those with Turner syndrome. The presentations and management of cardiovascular conditions in Turner syndrome differ significantly from the general population. Therefore, an international working group reviewed the available evidence regarding the diagnosis and treatment of cardiovascular diseases in Turner syndrome. It is recognized that the suggestions for clinical practice stated here are only the beginning of a process that must also involve the establishment of quality indicators, structures and processes for implementation, and outcome studies.

Aborted off-pump coronary artery bypass patients have much worse outcomes than on-pump or successful off-pump patients.

BACKGROUND: Off-pump coronary artery bypass graft (CABG) surgery is purported to reduce perioperative mortality and morbidity compared with on-pump coronary bypass graft surgery. However, the outcomes of patients for whom an off-pump strategy must be changed to an on-pump procedure during surgery have not been extensively studied. METHODS AND RESULTS: The Merged Cardiac Registry (Health Data Research, Inc) contains 70 514 isolated CABG performed from January 1998 to March 2004 in 40 facilities. Among them, 62 634 patients begun and completed on-pump bypass (CPB); 7880 patients begun off-pump, of which 7424 (94.2%) completed off-pump coronary artery bypass (OPCAB), whereas 456 (5.8%) were converted to on-pump (CONVERT). CONVERT patients were more severely ill. The observed mortality of CONVERT, CPB, and OPCAB was 9.9%, 3.0%, and 1.6%, respectively, and the observed-to-predicted ratio was 2.77, 1.20, and 0.74, respectively. CONVERT also had more morbidity than either OPCAB or CPB. Finally, a risk model was created to identify patients who might be at risk for conversion from off-pump to on-pump CABG. CONCLUSIONS: Patients who are intended for an off-pump strategy and then require conversion to on-pump have significantly higher operative mortality and morbidity than either completed OPCAB or CPB patients. In addition, the operative mortality and morbidity are far in excess of that predicted preoperatively. Based on these results, strong consideration should be given for a planned strategy of CPB for those patients with preoperative hemodynamic instability requiring a salvage CABG operation, left ventricular hypertrophy, or previous CABG.

Comparing on-pump and off-pump coronary artery bypass grafting: numerous studies but few conclusions: a scientific statement from the American Heart Association council on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research.

One of the most hotly debated and polarizing issues in cardiac surgery has been whether coronary artery bypass grafting (CABG) without the use of cardiopulmonary bypass or cardioplegia (off-pump CABG, or OPCAB) is superior to that performed with the heart-lung machine and the heart's being chemically arrested (standard CABG). Various clinical trials are reviewed comparing the 2 surgical strategies, including several large retrospective analyses, meta-analyses, and the randomized trials that address different aspects of standard CABG and OPCAB. Although definitive conclusions about the relative merits of standard CABG and OPCAB are difficult to reach from these varied randomized and nonrandomized studies, several generalizations may be possible. Patients may achieve an excellent outcome with either type of procedure, and individuals' outcomes likely depend more on factors other than whether they underwent standard CABG or OPCAB. Nevertheless, there appear to be trends in most studies. These trends include less blood loss and need for transfusion after OPCAB, less myocardial enzyme release after OPCAB up to 24 hours, less early neurocognitive dysfunction after OPCAB, and less renal insufficiency after OPCAB. Fewer grafts tend to be performed with OPCAB than with standard CABG. Length of hospital stay, mortality rate, and long-term neurological function and cardiac outcome appear to be similar in the 2 groups. To definitively answer the remaining questions of whether either strategy is superior and in which patients, a large-scale prospective randomized trial is required.