Racial and ethnic differences in aortic stenosis: the tip of the iceberg.

PURPOSE OF REVIEW: There is a lack of data on the epidemiology and management of severe aortic stenosis (AS) in diverse populations. We summarize the contemporary literature on the racial and ethnic differences in AS prevalence, treatment and outcomes and discuss possible explanations for these disparities to inform future research and improve the delivery of care to under-represented patient groups. RECENT FINDINGS: African American (AA) patients have significantly less prevalence of severe AS than White patients whereas paradoxically having higher traditional risk factors for severe AS. Non-White patients have less referral for aortic valve replacement (AVR) after adjusting for clinical and echocardiographic parameters. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are both underutilized in non-White patients. Differences in race and ethnicity have not shown to result in worse in-hospital and long-term survival outcomes after either SAVR or TAVR. SUMMARY: Much research is warranted to explore the epidemiology, true prevalence and treatment outcomes of severe AS in diverse populations. Greater inclusion of non-White ethnic groups in the primary analysis of prospective trials is needed. Lastly, further research is warranted to explore the complex causes of racial and ethnic disparities in utilization of surgical and transcatheter interventions.

Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis.

BACKGROUND: Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established. METHODS AND RESULTS: We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain] or [pain relief] OR [analgesics] or [analgesia] or [nerve block] or [regional block] or [local block] or [regional anesthesia] or [local anesthetic] or [parasternal block] and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by three independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24 to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to -0.25]) were significantly less in the PSB group. CONCLUSION: Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.

The use of ultrasound to assess aortic biomechanics: Implications for aneurysm and dissection.

Arterial stiffening, which occurs when conduit arteries thicken and lose elasticity, has been associated with cardiovascular disease and increased risk for future cardiovascular events. Specifically, aortic stiffening plays a large role in the pathogenesis of vascular diseases, such as aneurysm formation and dissection. Current parameters used to assess risk of aortic rupture include absolute diameter and growth rate. However, these properties lack the reliability required to accurately risk-stratify patients. As with any elastic conduit, it is important to assess the biomechanical properties of the aorta in order to assess cardiovascular risk and prevent disease progression. There are several invasive and noninvasive methods by which stiffness of the large arteries can be assessed. Of particular interest are ultrasound-based methods, such as tissue Doppler imaging and speckle-tracking echocardiography, due to their noninvasive and feasible nature. In this review, we summarize studies demonstrating utility of noninvasive ultrasound imaging methods for measuring aortic biomechanics for the assessment and management of aortic aneurysms.