A comprehensive review of the PARTNER trial

ObjectivePercutaneous transcatheter aortic valve replacement was introduced in 2002, but its effectiveness remained to be assessed.MethodsA prospective, randomized trial (the Placement of Aortic Transcatheter Valves, or PARTNER) was designed with 2 arms: PARTNER A (n = 699) for high-risk surgical patients (Society of Thoracic Surgeons score >10%, surgeon assessed risk of mortality >15%) and PARTNER B (n = 358, patients inoperable by assessment of 2 surgeons). PARTNER A patients were divided into femoral artery access transcatheter aortic valve replacement or none (n = 207), and then randomized to open aortic valve replacement (n = 351) or device (n = 348). Inclusion criteria included valve area <0.8 cm2, gradient >40 mm Hg or peak >64 mm Hg, and survival >1 year. The end point of the study was 1-year mortality.ResultsThirty-day mortality for PARTNER A was 3.4% for transcatheter aortic valve replacement and 6.5% for aortic valve replacement; 1-year mortality was 24.2% and 26.8%, respectively (P = .001 for noninferiority). The respective prevalence of stroke was 3.8% and 2.1% (P = .2), although for all neurologic events, the difference between transcatheter aortic valve replacement and aortic valve replacement was significant (P = .04), including 4.6% for femoral artery access transcatheter aortic valve replacement versus 1.4% for open aortic valve replacement (P = .05). For PARTNER B—transcatheter aortic valve replacement versus medical treatment—30-day mortality was 5.0% versus 2.8% (P = .41), and at 1 year, mortality was 30.7% versus 50.7% (P < .001), respectively. Hospitalization cost of transcatheter aortic valve replacement for PARTNER B was $78,542, or$50,200 per year of life gained. Analysis of PARTNER A strokes showed that hazard with transcatheter aortic valve replacement peaked early, but thereafter remained constant in relation to aortic valve replacement. Two-year PARTNER A data showed paravalvular regurgitation was associated with increased mortality, even when mild (P < .001). Continued access to transapical transcatheter aortic valve replacement (n = 853) showed a mortality of 8.2% and decline in strokes to 2.0%. Of the 1801 Cleveland Clinic patients reviewed to December 2010, 214 (12%) underwent transcatheter aortic valve replacement with a mortality of 1%; in 2011, 105 underwent transcatheter aortic valve replacement: 34 transapical aortic valve replacement, with no deaths, and 71 femoral artery access aortic valve replacement with 1 death.ConclusionsThe PARTNER A and B trials showed that survival has been remarkably good, but stroke and perivalvular leakage require further device development

Suboptimal geographic accessibility to comprehensive HIV care in the US: regional and urban–rural differences

Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county-level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban–rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co-located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillance data (2014), we used geographic analysis to estimate the fastest one-way drive time between the population-weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county-level drive time, population-weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was \u3e30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significance were not performed, since the analysis is population-based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county-level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county-level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban–rural differences in the West. Nationally, population-weighted drive time, an approximation of individual-level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority

Cardiopulmonary bypass via common carotid artery cannulation in redo sternotomy

There are certain situations in redo cardiac surgery in adults where it may not be possible to use alternate arterial cannulation sites like the common femoral artery and axillary artery. We report a case where we established safe cardiopulmonary bypass with common carotid artery cannulation in an adult patient. The patient underwent aortic valve replacement for severe aortic regurgitation 8 months after repair of type A aortic dissection plus aortic valve resuspension

Outcomes of less invasive J-incision approach to aortic valve surgery

ObjectiveLess invasive approaches to aortic valve surgery are increasingly used; however, few studies have investigated their impact on outcome. We sought to compare clinical outcomes after these approaches with full sternotomy using propensity-matching methods.MethodsFrom January 1995 to January 2004, a total of 2689 patients underwent isolated aortic valve surgery, 1193 via upper J-hemisternotomy and 1496 via full sternotomy. Because of important differences in patient characteristics between these groups, a propensity score based on 42 variables was used to obtain 832 well-matched patient pairs (70% of possible cases).ResultsIn-hospital mortality was identical for propensity-matched patients, 0.96% (8 in each). Occurrences of stroke (P > .9), renal failure (P = .8), and myocardial infarction (P = .7) were similar. However, 24-hour mediastinal drainage was a third less after less invasive surgery (median, 250 vs 350 mL; P < .0001), and fewer patients received transfusions (24% vs 34%; P < .0001). More patients undergoing less invasive surgery were extubated in the operating room (12% vs 1.6%; P < .0001), postoperative forced 1-second expiratory volume was higher (P = .009), and fewer had respiratory failure (P = .01). Early after operation, pain scores were lower (P < .0001) after less-invasive surgery and postoperative length of stay shorter (P < .0001).ConclusionsWithin that portion of the spectrum of isolated aortic valve surgery where propensity matching was possible, minimally invasive aortic valve surgery had not only cosmetic advantages, but blood product use, respiratory, pain, and resource utilization advantages over full sternotomy, and no apparent detriments. Less invasive aortic valve surgery should be considered for most aortic valve operations

Determination of the Jet Energy Scale at the Collider Detector at Fermilab

A precise determination of the energy scale of jets at the Collider Detector at Fermilab at the Tevatron $p\bar{p}$ collider is described. Jets are used in many analyses to estimate the energies of partons resulting from the underlying physics process. Several correction factors are developed to estimate the original parton energy from the observed jet energy in the calorimeter. The jet energy response is compared between data and Monte Carlo simulation for various physics processes, and systematic uncertainties on the jet energy scale are determined. For jets with transverse momenta above 50 GeV the jet energy scale is determined with a 3% systematic uncertainty

Socioeconomic Position, Not Race, Is Linked to Death After Cardiac Surgery

Background—Health disparities have been associated with the prevalence of cardiovascular disease. In cardiac surgery, association has been found between race, sex, and poorer prognosis after surgery. However, there is a complex interplay between race, sex, and socioeconomic position (SEP). In our investigation we sought to identify which of these was the driver of risk-adjusted survival. Methods and Results—From January 1, 1995, and December 30, 2005, 23 330 patients (15 156 white men, 6932 white women, 678 black men, and 564 black women) underwent isolated coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve procedures. Median follow-up was 5.8 years (25th and 75th percentiles: 3 and 8.6 years). Effect of race, sex, and SEP on all-cause mortality was examined with 2-phase Cox model and generalized propensity score technique. As expected, blacks and women had lower SEP as compared with whites and men for all 6 SEP indicators. Patients with lower SEP had more atherosclerotic disease burden, more comorbidity, and were more symptomatic. Lower SEP was associated with a risk-adjusted dose-dependent reduction in survival after surgery (men, P 0.0001; women, P 0.0079), but black race, once adjusted for SEP, was not. Conclusions—Our large investigation demonstrates that disparities in SEP are present and significantly affect health outcomes. Although race per se was not the driver for reduced survival, patients of low SEP were predominantly represented by blacks and women. Socioeconomically disadvantaged patients had significantly higher risk-adjusted mortality after surgery. Further investigation and targeted intervention should focus specifically on patients of low SEP, their health behaviors, and secondary prevention efforts.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79037/1/Koch_et_al.pd

Impact of left ventricular ejection fraction on clinical outcomes after left main coronary artery revascularization

Aim: To evaluate the impact of left ventricular ejection fraction (LVEF) on 3-year outcomes in patients with left main coronary artery disease (LMCAD) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the EXCEL trial. Methods and results: The EXCEL trial randomized patients with LMCAD to PCI with everolimus-eluting stents (n = 948) or CABG (n = 957). Among 1804 patients with known baseline LVEF, 74 (4.1%) had LVEF <40% [heart failure with reduced ejection fraction (HFrEF)], 152 (8.4%) LVEF 40–49% [heart failure with mid-range ejection fraction (HFmrEF)] and 1578 (87.5%) LVEF ≥50% (heart failure with preserved ejection fraction). Patients with HFrEF vs. HFmrEF vs. preserved LVEF experienced a longer postoperative hospital stay (9.0 vs. 7.0 vs. 6.0 days, P = 0.02) with greater peri-procedural complications after CABG, while hospital stay after PCI was unaffected by LVEF (1.5 vs. 2.0 vs. 1.0 days, P = 0.20). The composite primary endpoint of death, stroke, or myocardial infarction at 3 years was 29.3% (PCI) vs. 27.6% (CABG) in patients with HFrEF, 16.2% vs. 15.0% in patients with HFmrEF, and 14.5% vs. 14.6% in those with preserved LVEF, respectively (Pinteraction = 0.90). Smoothing spline analysis demonstrated that the 3-year risk of all-cause death increased when LVEF decreased, both in patients undergoing CABG and PCI. Conclusion: In the EXCEL trial, the composite rate of death, stroke or myocardial infarction at 3 years was significantly higher in patients with HFrEF compared with HFmrEF or preserved LVEF, driven by an increased rate of all-cause death. No significant differences after PCI vs. CABG were observed among patients with HFrEF, HFmrEF and preserved LVEF. Longer-term follow-up could provide important insights on differences in clinical outcomes that might emerge over time. Clinical Trial Registration: ClinicalTrials.gov ID NCT01205776