April 13th, 2015

Selections from Richard Lehman’s Literature Review: April 13th

CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

NEJM 9 Apr 2015 Vol 372

Randomized Trial of Primary PCI with or without Routine Manual Thrombectomy (pg. 1389): The major trials of coronary artery thrombus aspiration for myocardial infarction are TAPAS, TASTE, and TOTAL. Think of a bar crawl in Seville. The TAPAS and TASTE are obvious, and TOTAL could refer to the bill, which is sometimes just chalked on the surface you’re leaning on, or to your state of inebriation after eight glasses of fino sherry. Either way, these bars are more interesting than this procedure, which is now ready for burial as a routine intervention for MI. Both TASTE and TOTAL find that it does not improve cardiac outcomes and TOTAL finds an increase in stroke. The accompanying editorial thinks it may yet prove of benefit to high-risk patients, citing observational follow-up and post-hoc subgroup analysis. Maybe one further trial needed in such patients before saying ADIOS to the bartender. But why does cardiology come up with so many failed hopes? It seems so obvious that sucking out a clot as soon as it has blocked a coronary artery will be of benefit, but it just isn’t. Even procedures we believe in, like timely percutaneous intervention for MI, aren’t having the impact we hoped for. The editorial also points out that, “Although door-to-balloon times have improved significantly over the past 10 years, in-hospital mortality for STEMI has remained virtually unchanged.”

Surgical Ablation of Atrial Fibrillation during Mitral-Valve Surgery (pg. 1399): Now let’s move on to mitral valve surgery and atrial fibrillation. It seems clear we can fix this with a mixture of plumbing and electrical engineering. It gets quite sophisticated: “We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage.” The primary end-point of the trial was abolition of AF, and by that criterion it was a success, with twice as many in the intervention group remaining free from AF at the end of year. But more than twice as many (21.5%) of the intervention group need to have a permanent pacemaker fitted. “Establishing the effects of ablation on long-term survival, stroke incidence, the need for rehospitalization, repeat rhythm procedures, and freedom from anticoagulation therapy requires further study.”


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