CLINICAL
NEWS JACC in a FLASH
Featured topics in the current and recent
issues of the JACC family of journals
Twisting of the Heart May Predict
Mitral Valve Surgery Outcomes
Assessing left ventricular torsion may
help predict the outcome of mitral
valve surgery in symptomatic patients
with nonischemic, chronic secondary
severe mitral regurgitation (NICSMR),
according to a recent novel study published in JACC: Basic to Translational
Science.
Yuichi Notomi, MD, and colleagues examined 50 consecutive
symptomatic NICSMR patients for
a median follow-up of 2.5 years
after mitral surgery. All patients had
advanced heart failure (HF) symptoms and had already received the
maximum guideline-directed medical
therapy for more than 6 months. Patients were divided into three groups:
preserved left ventricular torsion, lost
left ventricular torsion, or patients
with a wide QRS measurement who
received cardiac resynchronization
therapy. Each patient received either
mitral valve repair or mitral valve
replacement.
Two years after surgery, 19
patients had died. Baseline left ventricular size, shape and mass tended
to be larger and more spherical in
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those who died, but not significantly
so, while left ventricular torsion
was higher in survivors. Researchers determined that in patients with
NICSMR and a narrow QRS width,
preserved left ventricular torsion may
be a better predictor of post-mitral
surgery survival, while conversely,
lost left ventricular torsion may lead
to a poor post-surgical outcome.
Researchers also noted that
patients who received cardiac
resynchronization therapy prior to
mitral surgery showed significantly
worse 2-year survival than those who
received the procedure during mitral
surgery. However, the two groups had
similar left ventricular torsion.
According to study authors, the
results suggest mitral surgery is an
acceptable option in patients with
preserved left-ventricular torsion and
a narrow QRS measurement. They
also point out that left ventricular
torsion can help to predict post-mitral
surgery outcomes in patients with a
narrow QRS but not in those with a
wide QRS.
“Mechanistically, this study sug-
gests that the loss of torsion in patients with HF may reflect irreversible
structural damage to the heart which
would prevent the heart from recovering after corrective surgery,” says
Douglas L. Mann, MD, editor-in-chief
of JACC: Basic to Translational Science. “If correct, this will have much
broader implications than improvement after mitral valve surgery since
it may predict which patients with HF
may get better on medications.”
According to Mann, these findings
will need confirmation as the analysis
was retrospective and took place in
a small number of patients. Kim A.
Eagle, MD, editor-in-chief of ACC.org,
agrees and notes that “with only data
on 50 individuals, we need much
larger data sets to see if this type of
imaging could guide treatment.”
Notomi Y, Isomura T, Kanai S, et al. JACC:
Basic to Translational Science. 2016;1(4):193202.
Study Shows Few
Periprocedural
Anticoagulation
Management
Standards Exist
There is a need to develop standardized protocols for the interruption of
oral anticoagulation for surgery and
invasive procedures, according to
results of a study published July 4 in
JACC.
Because the management of parenteral anticoagulation is a complex
process and requires coordination
between health care providers, the
ACC Anticoagulation Initiative Work
Group developed a survey to help
“better understand current practice
patterns for patients requiring interruption of anticoagulation therapy.”
In a review of background data,
study authors Greg C. Flaker, MD, et
al., note that there is little evidence to
“With only
data on 50
individuals,
we need much
larger data sets
to see if this
type of imaging
could guide
treatment.”
—Kim A. Eagle, MD
show that bridging anticoagulation
prevents thromboembolic events (TE).
An earlier review and analysis of
patients who required interruption of
vitamin K antagonist therapy showed
“no significant differences in TE
between those patients who received
parenteral anticoagulation and those
who did not.” Significant occurrences
of major bleeding were noted in the
patients who received parenteral
anticoagulation. Similar results were
found in the BRIDGE trial in which
patients were randomized to dalteparin or placebo.
The authors also assert that a
number of surgical procedures with
low bleeding risk can be performed
with “brief or no interruption of
warfarin,” which reduces the need
for parenteral anticoagulation and
additional bleeding risk. Further, the
August 2016