ACS Surgery News

The U.S. Supreme Court has agreed to review a case challenging the legality of federal subsidies provided under the Affordable Care Act.

©trekandshoot/thinkstockphotos.com

The Court issued the order Nov. 7, granting the plaintiffs in King v. Burwell a review of the case. The plaintiffs assert that under the ACA, only state marketplaces can issue subsidies to eligible patients.

In July, the Fourth Circuit Court of Appeals ruled against the plaintiffs, upholding the government’s ability to provide subsidies to eligible patients who purchase insurance through the 36 federally facilitated health care marketplaces.

On the same day, a limited panel of judges on the District of Columbia Circuit of the U.S. Court of Appeals ruled that the federal marketplace subsidies were not legal in a similar challenge, Halbig v. Burwell.

The government appealed, seeking a full review, which was granted in September. All 17 D.C. Circuit judges will review the case on Dec. 17.

The Supreme Court is not likely to hear King v. Burwell before that date.

[email protected]

On Twitter @aliciaault

The U.S. Supreme Court has agreed to review a case challenging the legality of federal subsidies provided under the Affordable Care Act.

©trekandshoot/thinkstockphotos.com

The Court issued the order Nov. 7, granting the plaintiffs in King v. Burwell a review of the case. The plaintiffs assert that under the ACA, only state marketplaces can issue subsidies to eligible patients.

In July, the Fourth Circuit Court of Appeals ruled against the plaintiffs, upholding the government’s ability to provide subsidies to eligible patients who purchase insurance through the 36 federally facilitated health care marketplaces.

On the same day, a limited panel of judges on the District of Columbia Circuit of the U.S. Court of Appeals ruled that the federal marketplace subsidies were not legal in a similar challenge, Halbig v. Burwell.

The government appealed, seeking a full review, which was granted in September. All 17 D.C. Circuit judges will review the case on Dec. 17.

The Supreme Court is not likely to hear King v. Burwell before that date.

[email protected]

On Twitter @aliciaault

The U.S. Supreme Court has agreed to review a case challenging the legality of federal subsidies provided under the Affordable Care Act.

©trekandshoot/thinkstockphotos.com

The Court issued the order Nov. 7, granting the plaintiffs in King v. Burwell a review of the case. The plaintiffs assert that under the ACA, only state marketplaces can issue subsidies to eligible patients.

In July, the Fourth Circuit Court of Appeals ruled against the plaintiffs, upholding the government’s ability to provide subsidies to eligible patients who purchase insurance through the 36 federally facilitated health care marketplaces.

On the same day, a limited panel of judges on the District of Columbia Circuit of the U.S. Court of Appeals ruled that the federal marketplace subsidies were not legal in a similar challenge, Halbig v. Burwell.

The government appealed, seeking a full review, which was granted in September. All 17 D.C. Circuit judges will review the case on Dec. 17.

The Supreme Court is not likely to hear King v. Burwell before that date.

[email protected]

On Twitter @aliciaault

Medicare won’t pay physicians for counseling their patients on advance care directives in 2015, but they are open to doing it sometime in the future.

In the 2015 Medicare Physician Fee Schedule, federal officials said they “will consider” whether to pay for codes related to advance care planning services after they have had the opportunity to go through notice and comment rulemaking.

The final physician payment rule, which was released on Oct. 31, highlights two codes recently created by the American Medical Association’s Relative Value Update Committee. The CPT code 99497 covers the first 30 minutes of a face-to-face discussion with the patient, family member, or surrogate about advance directives, as well as the completion of forms. The add-on CPT code 99498 covers each additional 30 minutes.

Physicians can use the new codes, but Medicare will not pay for them in 2015, according to the rule.

Dr. Diane E. Meier, director of the Center to Advance Palliative Care, said the agency’s decision not to move forward immediately with payment is not a surprise. “I think it’s promising,” she said. “I think it’s not surprising that they are being extremely cautious and hesitant given the political firestorm that an effort to do this created in 2009.”

Public opinion on end-of-life care is beginning to shift, Dr. Meier said, which could bode well for future Medicare payment. But payment is only one barrier to making counseling available to all patients. Training physicians and other health care providers in how to have conversations about the end of life is a far bigger hurdle, she said.

“If the clinician is afraid, uncomfortable, doesn’t even know how to begin, it doesn’t matter if there’s a payment,” she said. “They’re not going to do it.”

There has been some momentum building for Medicare payment for end-of-life counseling, including pressure from Congress. In September, 34 members of the U.S. House of Representatives wrote to CMS urging them to begin paying for the newly created codes 99497 and 99498.

The Institute of Medicine in its September report, Dying in America, also recommended that physicians be compensated for counseling patients on end-of-life planning.

[email protected]

On Twitter @maryellenny

Medicare won’t pay physicians for counseling their patients on advance care directives in 2015, but they are open to doing it sometime in the future.

In the 2015 Medicare Physician Fee Schedule, federal officials said they “will consider” whether to pay for codes related to advance care planning services after they have had the opportunity to go through notice and comment rulemaking.

The final physician payment rule, which was released on Oct. 31, highlights two codes recently created by the American Medical Association’s Relative Value Update Committee. The CPT code 99497 covers the first 30 minutes of a face-to-face discussion with the patient, family member, or surrogate about advance directives, as well as the completion of forms. The add-on CPT code 99498 covers each additional 30 minutes.

Physicians can use the new codes, but Medicare will not pay for them in 2015, according to the rule.

Dr. Diane E. Meier, director of the Center to Advance Palliative Care, said the agency’s decision not to move forward immediately with payment is not a surprise. “I think it’s promising,” she said. “I think it’s not surprising that they are being extremely cautious and hesitant given the political firestorm that an effort to do this created in 2009.”

Public opinion on end-of-life care is beginning to shift, Dr. Meier said, which could bode well for future Medicare payment. But payment is only one barrier to making counseling available to all patients. Training physicians and other health care providers in how to have conversations about the end of life is a far bigger hurdle, she said.

“If the clinician is afraid, uncomfortable, doesn’t even know how to begin, it doesn’t matter if there’s a payment,” she said. “They’re not going to do it.”

There has been some momentum building for Medicare payment for end-of-life counseling, including pressure from Congress. In September, 34 members of the U.S. House of Representatives wrote to CMS urging them to begin paying for the newly created codes 99497 and 99498.

The Institute of Medicine in its September report, Dying in America, also recommended that physicians be compensated for counseling patients on end-of-life planning.

[email protected]

On Twitter @maryellenny

Medicare won’t pay physicians for counseling their patients on advance care directives in 2015, but they are open to doing it sometime in the future.

In the 2015 Medicare Physician Fee Schedule, federal officials said they “will consider” whether to pay for codes related to advance care planning services after they have had the opportunity to go through notice and comment rulemaking.

The final physician payment rule, which was released on Oct. 31, highlights two codes recently created by the American Medical Association’s Relative Value Update Committee. The CPT code 99497 covers the first 30 minutes of a face-to-face discussion with the patient, family member, or surrogate about advance directives, as well as the completion of forms. The add-on CPT code 99498 covers each additional 30 minutes.

Physicians can use the new codes, but Medicare will not pay for them in 2015, according to the rule.

Dr. Diane E. Meier, director of the Center to Advance Palliative Care, said the agency’s decision not to move forward immediately with payment is not a surprise. “I think it’s promising,” she said. “I think it’s not surprising that they are being extremely cautious and hesitant given the political firestorm that an effort to do this created in 2009.”

Public opinion on end-of-life care is beginning to shift, Dr. Meier said, which could bode well for future Medicare payment. But payment is only one barrier to making counseling available to all patients. Training physicians and other health care providers in how to have conversations about the end of life is a far bigger hurdle, she said.

“If the clinician is afraid, uncomfortable, doesn’t even know how to begin, it doesn’t matter if there’s a payment,” she said. “They’re not going to do it.”

There has been some momentum building for Medicare payment for end-of-life counseling, including pressure from Congress. In September, 34 members of the U.S. House of Representatives wrote to CMS urging them to begin paying for the newly created codes 99497 and 99498.

The Institute of Medicine in its September report, Dying in America, also recommended that physicians be compensated for counseling patients on end-of-life planning.

[email protected]

On Twitter @maryellenny

SAN FRANCISCO– A large retrospective study identified risk factors for anastomotic leak within 30 days of colectomy.

The analysis of data on 13,684 patients looked at a multicenter cohort, compared with previous smaller studies that generally focused on single institutions, Dr. Emily F. Midura and her associates reported at the annual clinical congress of the American College of Surgeons.

In a video interview at the meeting, Dr. Midura described the risk factors identified in the study.

The 4% of patients who developed a leak averaged 13 days in the hospital, compared with 8 days for patients with no leak, said Dr. Midura of the University of Cincinnati. A total of 6% of patients who developed an anastomotic leak died, compared with a 2% mortality rate in patients without a leak.

Indications for colectomy included cancer in 42% of patients, diverticulitis in 23%, inflammatory bowel disease in 6%, and other reasons in the rest of the cohort.

Dr. Midura reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO– A large retrospective study identified risk factors for anastomotic leak within 30 days of colectomy.

The analysis of data on 13,684 patients looked at a multicenter cohort, compared with previous smaller studies that generally focused on single institutions, Dr. Emily F. Midura and her associates reported at the annual clinical congress of the American College of Surgeons.

In a video interview at the meeting, Dr. Midura described the risk factors identified in the study.

The 4% of patients who developed a leak averaged 13 days in the hospital, compared with 8 days for patients with no leak, said Dr. Midura of the University of Cincinnati. A total of 6% of patients who developed an anastomotic leak died, compared with a 2% mortality rate in patients without a leak.

Indications for colectomy included cancer in 42% of patients, diverticulitis in 23%, inflammatory bowel disease in 6%, and other reasons in the rest of the cohort.

Dr. Midura reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO– A large retrospective study identified risk factors for anastomotic leak within 30 days of colectomy.

The analysis of data on 13,684 patients looked at a multicenter cohort, compared with previous smaller studies that generally focused on single institutions, Dr. Emily F. Midura and her associates reported at the annual clinical congress of the American College of Surgeons.

In a video interview at the meeting, Dr. Midura described the risk factors identified in the study.

The 4% of patients who developed a leak averaged 13 days in the hospital, compared with 8 days for patients with no leak, said Dr. Midura of the University of Cincinnati. A total of 6% of patients who developed an anastomotic leak died, compared with a 2% mortality rate in patients without a leak.

Indications for colectomy included cancer in 42% of patients, diverticulitis in 23%, inflammatory bowel disease in 6%, and other reasons in the rest of the cohort.

Dr. Midura reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Venous thromboembolism is about 50% more likely when trauma patients are transfused with more than 1 unit of fresh frozen plasma for every 2 units of red blood cells, according to a retrospective review of 139,842 adult patients in the National Trauma Data Bank, all of whom received at least 1 unit of red blood cells from 2007 to 2012.

The risk quadrupled when patients received 6 or more red blood cell (RBC) units; for those patients, the only independent risk factor for venous thromboembolism (VTE) was transfusion with more than 1 unit of fresh frozen plasma (FFP) per 2 units of RBCs (odds ratio, 4.12; P = .011).

When patients get that much plasma, they “should be monitored closely for deep vein thrombosis [DVT] and pulmonary embolism [PE], and started on VTE prophylaxis as soon as possible,” said lead investigator Dr. Gregory Magee, a trauma and critical care fellow at the University of Southern California, Los Angeles. The findings complicate an emerging idea of how best to transfuse trauma patients. A 2013 investigation found that 6-hour survival is significantly higher when patients get more plasma with their RBCs than they might have in the past, at least 1 FFP unit for every 2 RBC units. Some research suggests that a 1:1 ratio might be even better (JAMA Surg. 2013;148:127-36). “You need to do what you need to do to help your patients survive,” but there should be a “balancing act to make sure they have enough clotting factors [onboard] to stop the bleeding, but not enough to cause thrombosis,” Dr. Magee said at the annual clinical congress of the American College of Surgeons.

The rate of transfusion-associated PEs in his study was 0.4%, and the rate of DVTs 0.8%. How serious they were is not known; the information was unavailable in the database review. Though low, the incidence of thrombosis increased with increasing volumes of transfused RBCs.

In addition to the 50% increased risk of VTE with higher volumes of transfused plasma (OR 1.47, P < .001), VTE was independently associated with transfusions of 6 or more RBC units (OR 2.10, P = .001); blunt trauma (OR 1.49, P = .001); male gender (OR 1.29, P < .001); and Abbreviated Injury Scale (AIS) scores of 3 or higher for chest injuries (OR 1.30, P < .001), head injuries (OR 1.18, P = .032), and lower extremity injuries (OR 1.16, P = .034).

Several of Dr. Magee’s colleagues are coinvestigators on a recently concluded randomized transfusion trial that pitted plasma, platelet, and RBC ratios of 1:1:1 and 1:1:2 against each other, looking for survival and complication differences. They hope to publish their results soon, he said. The randomized study was the only way to counter the survival bias that might have been at work in the 2013 investigation, which was a prospective cohort study. Higher volumes of plasma might have improved survival, but it’s possible that patients who lived longer were more likely to get FFP, since it’s often administered well after RBC transfusions are underway.

For now, “we don’t know which one is best or if it makes a difference,” Dr. Magee said.

Dr. Magee had no disclosures. The work was funded in part by the National Institutes of Health.

[email protected]

SAN FRANCISCO – Venous thromboembolism is about 50% more likely when trauma patients are transfused with more than 1 unit of fresh frozen plasma for every 2 units of red blood cells, according to a retrospective review of 139,842 adult patients in the National Trauma Data Bank, all of whom received at least 1 unit of red blood cells from 2007 to 2012.

The risk quadrupled when patients received 6 or more red blood cell (RBC) units; for those patients, the only independent risk factor for venous thromboembolism (VTE) was transfusion with more than 1 unit of fresh frozen plasma (FFP) per 2 units of RBCs (odds ratio, 4.12; P = .011).

When patients get that much plasma, they “should be monitored closely for deep vein thrombosis [DVT] and pulmonary embolism [PE], and started on VTE prophylaxis as soon as possible,” said lead investigator Dr. Gregory Magee, a trauma and critical care fellow at the University of Southern California, Los Angeles. The findings complicate an emerging idea of how best to transfuse trauma patients. A 2013 investigation found that 6-hour survival is significantly higher when patients get more plasma with their RBCs than they might have in the past, at least 1 FFP unit for every 2 RBC units. Some research suggests that a 1:1 ratio might be even better (JAMA Surg. 2013;148:127-36). “You need to do what you need to do to help your patients survive,” but there should be a “balancing act to make sure they have enough clotting factors [onboard] to stop the bleeding, but not enough to cause thrombosis,” Dr. Magee said at the annual clinical congress of the American College of Surgeons.

The rate of transfusion-associated PEs in his study was 0.4%, and the rate of DVTs 0.8%. How serious they were is not known; the information was unavailable in the database review. Though low, the incidence of thrombosis increased with increasing volumes of transfused RBCs.

In addition to the 50% increased risk of VTE with higher volumes of transfused plasma (OR 1.47, P < .001), VTE was independently associated with transfusions of 6 or more RBC units (OR 2.10, P = .001); blunt trauma (OR 1.49, P = .001); male gender (OR 1.29, P < .001); and Abbreviated Injury Scale (AIS) scores of 3 or higher for chest injuries (OR 1.30, P < .001), head injuries (OR 1.18, P = .032), and lower extremity injuries (OR 1.16, P = .034).

Several of Dr. Magee’s colleagues are coinvestigators on a recently concluded randomized transfusion trial that pitted plasma, platelet, and RBC ratios of 1:1:1 and 1:1:2 against each other, looking for survival and complication differences. They hope to publish their results soon, he said. The randomized study was the only way to counter the survival bias that might have been at work in the 2013 investigation, which was a prospective cohort study. Higher volumes of plasma might have improved survival, but it’s possible that patients who lived longer were more likely to get FFP, since it’s often administered well after RBC transfusions are underway.

For now, “we don’t know which one is best or if it makes a difference,” Dr. Magee said.

Dr. Magee had no disclosures. The work was funded in part by the National Institutes of Health.

[email protected]

SAN FRANCISCO – Venous thromboembolism is about 50% more likely when trauma patients are transfused with more than 1 unit of fresh frozen plasma for every 2 units of red blood cells, according to a retrospective review of 139,842 adult patients in the National Trauma Data Bank, all of whom received at least 1 unit of red blood cells from 2007 to 2012.

The risk quadrupled when patients received 6 or more red blood cell (RBC) units; for those patients, the only independent risk factor for venous thromboembolism (VTE) was transfusion with more than 1 unit of fresh frozen plasma (FFP) per 2 units of RBCs (odds ratio, 4.12; P = .011).

When patients get that much plasma, they “should be monitored closely for deep vein thrombosis [DVT] and pulmonary embolism [PE], and started on VTE prophylaxis as soon as possible,” said lead investigator Dr. Gregory Magee, a trauma and critical care fellow at the University of Southern California, Los Angeles. The findings complicate an emerging idea of how best to transfuse trauma patients. A 2013 investigation found that 6-hour survival is significantly higher when patients get more plasma with their RBCs than they might have in the past, at least 1 FFP unit for every 2 RBC units. Some research suggests that a 1:1 ratio might be even better (JAMA Surg. 2013;148:127-36). “You need to do what you need to do to help your patients survive,” but there should be a “balancing act to make sure they have enough clotting factors [onboard] to stop the bleeding, but not enough to cause thrombosis,” Dr. Magee said at the annual clinical congress of the American College of Surgeons.

The rate of transfusion-associated PEs in his study was 0.4%, and the rate of DVTs 0.8%. How serious they were is not known; the information was unavailable in the database review. Though low, the incidence of thrombosis increased with increasing volumes of transfused RBCs.

In addition to the 50% increased risk of VTE with higher volumes of transfused plasma (OR 1.47, P < .001), VTE was independently associated with transfusions of 6 or more RBC units (OR 2.10, P = .001); blunt trauma (OR 1.49, P = .001); male gender (OR 1.29, P < .001); and Abbreviated Injury Scale (AIS) scores of 3 or higher for chest injuries (OR 1.30, P < .001), head injuries (OR 1.18, P = .032), and lower extremity injuries (OR 1.16, P = .034).

Several of Dr. Magee’s colleagues are coinvestigators on a recently concluded randomized transfusion trial that pitted plasma, platelet, and RBC ratios of 1:1:1 and 1:1:2 against each other, looking for survival and complication differences. They hope to publish their results soon, he said. The randomized study was the only way to counter the survival bias that might have been at work in the 2013 investigation, which was a prospective cohort study. Higher volumes of plasma might have improved survival, but it’s possible that patients who lived longer were more likely to get FFP, since it’s often administered well after RBC transfusions are underway.

For now, “we don’t know which one is best or if it makes a difference,” Dr. Magee said.

Dr. Magee had no disclosures. The work was funded in part by the National Institutes of Health.

[email protected]

CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.

Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.

Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).

A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).

“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.

The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.

A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.

“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.

The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.

Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.

The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).

Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).

Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.

A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).

An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”

“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”

Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.

[email protected]

CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.

Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.

Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).

A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).

“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.

The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.

A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.

“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.

The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.

Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.

The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).

Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).

Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.

A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).

An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”

“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”

Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.

[email protected]

CHICAGO – Ten times as many papers were published on the mitral valve as were published on the tricuspid valve during the 1990s, based on a literature review.

Things have picked up over the past decade, however, for the “forgotten,” little-respected “Rodney Dangerfield” valve, with surgeons writing more about tricuspid regurgitation and doing more tricuspid surgery than ever before, Dr. Patrick McCarthy said at Heart Valve Summit 2014.

Tricuspid interventions more than doubled from 1999 to 2008, although overall hospital mortality was substantial at 10.6%. (J. Thorac. Cardiovasc. Surg. 2012;143:1043-9).

A Society of Thoracic Surgeons risk model containing intraoperative variables showed that multiple-valve surgery mortality is more than twice that of single-valve surgery, but that performance of arrhythmia ablation and atrioventricular valve repair are protective for mortality (Ann. Thorac. Surg. 2013;95:1484-90).

“There isn’t any data that the tricuspid per se is actually the reason that the operation is higher risk,” said Dr. McCarthy, director of the Bluhm Cardiovascular Institute and chief of cardiac surgery, Northwestern University in Chicago.

The new American Heart Association/American College of Cardiology (AHA/ACC) guideline on valvular heart disease, published earlier this year, reflects the changing attitudes about mitral valve surgery and the need for earlier intervention.

A class I indication for surgery remains in place for severe tricuspid regurgitation (TR) with mitral valve disease. However, what had been a class IIb indication in the 2006 guidelines for primary TR with symptoms is now a class I indication in the 2014 guidelines.

“Don’t wait for right ventricular failure in primary TR. Plan for earlier intervention, and think of it more like we do mitral regurgitation,” Dr. McCarthy said.

The recommendation for more moderate TR has also changed. The class IIb recommendation for patients with less than severe TR during mitral valve repair with pulmonary hypertension, right heart failure, or tricuspid dilation is now class IIa, indicating a lower threshold for surgery for these patients, he said.

Asymptomatic primary TR with right ventricle dilation or reoperations for TR with symptoms and prior left heart surgery had been a class III indication against surgery in 2006, but are now in sync with the European valvular guidelines with a class IIb indication, suggesting surgery may be considered.

The move toward earlier surgery is supported by results showing that TR only gets worse if left untreated, Dr. McCarthy said. Among patients with annular dilation greater than 70 mm as the only criterion for tricuspid valve repair (TVR), TR was shown to increase by more than 2 grades after 2 years in just 2% of patients who underwent TVR during mitral valve repair (MVR), versus 48% without TVR (Ann. Thorac. Surg. 2005;79:127-32).

Another study showed that prophylactic tricuspid annuloplasty in patients with dilated tricuspid annulus undergoing MVR reduces the rate of TR progression, improves right ventricular remodeling, and improves functional outcomes on the 6-minute walk test (J. Thorac. Cardiovasc. Surg. 2012;143:632-8).

Not all data, however, have been viewed through the same lens, with the “Mayo Clinic and Cleveland Clinic finding the same thing but drawing different conclusions,” Dr. McCarthy observed.

A Cleveland Clinic analysis involving 1,833 patients with degenerative mitral valve disease reported that MVR alone improved TR and right ventricular function in patients with severe TR (grade 3+/4+), but that improvements were incomplete and temporary. In contrast, MVR with concomitant TVR eliminated severe TR and improved RV function toward normal, “supporting an aggressive approach to important functional tricuspid regurgitation” (J. Cardiovasc Surg. 2013;146:1126-32).

An 11-year review by the Mayo Clinic in Rochester, Minn., involving 699 patients with functional TR and degenerative mitral valve leaflet prolapse also showed that MVR alone significantly reduced TR within the first year in all patients and produced significant decreases until the third year in those with severe regurgitation. Only one patient required tricuspid reoperation 4.5 years after mitral repair. The authors argued for a selective approach to TR, concluding that “tricuspid valve surgery is rarely necessary for most patients undergoing repair of isolated mitral valve prolapse.”

“While both Cleveland and Mayo Clinic found that untreated TR persisted, Mayo interpreted the rare need for reoperation and no decrease in 5-year survival as evidence that it need not be repaired, while Cleveland suggested with the evidence of improved RV function that it should be repaired,” Dr. McCarthy said in an interview. “The European Society of Cardiology and AHA/ACC guidelines would support the approach from the Cleveland Clinic.”

Dr. McCarthy disclosed inventing the Edwards MC3 tricuspid valve repair ring.

[email protected]

LAS VEGAS – The experience at one major heart transplantation center indicates that annual screening dobutamine stress echocardiography to detect cardiac allograft vasculopathy renders annual coronary angiography unnecessary.

“This noninvasive method has very good specificity and is associated with a negative predictive value of 94%-97%. It can be used in our experience in lieu of annual invasive coronary angiography,” Dr. Jerry D. Estep declared at the annual meeting of the Heart Failure Society of America.

Cardiac allograft vasculopathy (CAV) is a unique, highly aggressive form of CAD. After 3 years post transplant it becomes the No. 1 cause of cardiac retransplantation and mortality. Guidelines recommend consideration of annual screening coronary angiography to detect it early to institute aggressive countermeasures. That’s the practice at most transplant centers.

However, at Houston Methodist Hospital, where Dr. Estep is medical director of the heart transplant and LVAD program, annual dobutamine stress echocardiography (DSE) is used instead. Because there is a scarcity of published data on this noninvasive alternative approach, he presented a retrospective study of the Houston transplant center’s experience over a recent 5-year period.

The study included 144 heart transplant recipients who underwent screening DSE for CAV annually for the first 4 years post transplant and coronary angiography at year 5.

During years 1-4, DSE detected CAV in 19% of patients. They didn’t differ in terms of baseline characteristics from those who remained free of this serious complication.

The good news: Ninety-four percent of patients with normal DSEs during years 1-4 had no CAV upon angiography at year 5. Moreover, the 5% who did have CAV at year 5 after earlier negative DSEs had mild to moderate disease.

The investigators documented the performance of annual screening DSE in predicting the development of major adverse cardiac events, defined as readmission for acute coronary syndrome, heart failure, revascularization, repeat heart transplantation, or cardiac death.

Dr. Estep reported having no financial conflicts regarding this study.

[email protected]

LAS VEGAS – The experience at one major heart transplantation center indicates that annual screening dobutamine stress echocardiography to detect cardiac allograft vasculopathy renders annual coronary angiography unnecessary.

“This noninvasive method has very good specificity and is associated with a negative predictive value of 94%-97%. It can be used in our experience in lieu of annual invasive coronary angiography,” Dr. Jerry D. Estep declared at the annual meeting of the Heart Failure Society of America.

Cardiac allograft vasculopathy (CAV) is a unique, highly aggressive form of CAD. After 3 years post transplant it becomes the No. 1 cause of cardiac retransplantation and mortality. Guidelines recommend consideration of annual screening coronary angiography to detect it early to institute aggressive countermeasures. That’s the practice at most transplant centers.

However, at Houston Methodist Hospital, where Dr. Estep is medical director of the heart transplant and LVAD program, annual dobutamine stress echocardiography (DSE) is used instead. Because there is a scarcity of published data on this noninvasive alternative approach, he presented a retrospective study of the Houston transplant center’s experience over a recent 5-year period.

The study included 144 heart transplant recipients who underwent screening DSE for CAV annually for the first 4 years post transplant and coronary angiography at year 5.

During years 1-4, DSE detected CAV in 19% of patients. They didn’t differ in terms of baseline characteristics from those who remained free of this serious complication.

The good news: Ninety-four percent of patients with normal DSEs during years 1-4 had no CAV upon angiography at year 5. Moreover, the 5% who did have CAV at year 5 after earlier negative DSEs had mild to moderate disease.

The investigators documented the performance of annual screening DSE in predicting the development of major adverse cardiac events, defined as readmission for acute coronary syndrome, heart failure, revascularization, repeat heart transplantation, or cardiac death.

Dr. Estep reported having no financial conflicts regarding this study.

[email protected]

LAS VEGAS – The experience at one major heart transplantation center indicates that annual screening dobutamine stress echocardiography to detect cardiac allograft vasculopathy renders annual coronary angiography unnecessary.

“This noninvasive method has very good specificity and is associated with a negative predictive value of 94%-97%. It can be used in our experience in lieu of annual invasive coronary angiography,” Dr. Jerry D. Estep declared at the annual meeting of the Heart Failure Society of America.

Cardiac allograft vasculopathy (CAV) is a unique, highly aggressive form of CAD. After 3 years post transplant it becomes the No. 1 cause of cardiac retransplantation and mortality. Guidelines recommend consideration of annual screening coronary angiography to detect it early to institute aggressive countermeasures. That’s the practice at most transplant centers.

However, at Houston Methodist Hospital, where Dr. Estep is medical director of the heart transplant and LVAD program, annual dobutamine stress echocardiography (DSE) is used instead. Because there is a scarcity of published data on this noninvasive alternative approach, he presented a retrospective study of the Houston transplant center’s experience over a recent 5-year period.

The study included 144 heart transplant recipients who underwent screening DSE for CAV annually for the first 4 years post transplant and coronary angiography at year 5.

During years 1-4, DSE detected CAV in 19% of patients. They didn’t differ in terms of baseline characteristics from those who remained free of this serious complication.

The good news: Ninety-four percent of patients with normal DSEs during years 1-4 had no CAV upon angiography at year 5. Moreover, the 5% who did have CAV at year 5 after earlier negative DSEs had mild to moderate disease.

The investigators documented the performance of annual screening DSE in predicting the development of major adverse cardiac events, defined as readmission for acute coronary syndrome, heart failure, revascularization, repeat heart transplantation, or cardiac death.

Dr. Estep reported having no financial conflicts regarding this study.

[email protected]

PHILADELPHIA – Obesity and diabetes are independent risk factors for invasive group A Streptococcus infections, with the highest risk among those with diabetes and morbid obesity.

The relative risk of invasive group A Streptococcus (iGAS) infection was 15 times higher in adults with diabetes and grade 3 morbid obesity (body mass index ≥ 40 kg/m²) than in those of normal weight, Dr. Gayle Langley reported at Infectious Diseases Week 2014.

Moreover, grades 1-2 obesity and morbid obesity increased the odds of ICU admission and death from an iGAS infection in multivariable logistic regression.

The adjusted odds ratios for ICU admission and death were 1.46 and 1.55 for patients with grades 1-2 obesity (BMI 30 < 40 kg/m²) and 2.07 and 1.62 for those with morbid obesity, she said.

Diabetes was not associated with an increased risk for either ICU admission (odds ratio, 1.06) or death (OR, 0.77) in the analysis.

Skin and soft tissue infections, which were significantly more common in obese and diabetic patients, appear to be driving the increased risk for iGAS in these groups, Dr. Langley of the Centers for Disease Control and Prevention said in an interview.

“Based on the literature, I’m not all that surprised because we definitely know that they are at increased risk for these skin and soft tissue infections, and that is a common manifestation of strep,” she said. “The mortality is slightly increased, but not to the extent of the incidence.”

The study was prompted by the limited number of prevention strategies for what Langley described as a “really serious infection” and by the rise in obesity and diabetes in the United States.

Data from select counties in 10 of the CDC’s Active Bacterial Core surveillance sites were used to identify 2,927 cases of 2010-2012 community onset iGAS. Cases were defined by isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis or streptococcal toxic shock syndrome in a resident in the surveillance area. Clinical data were obtained from medical records, with height and weight used to calculate BMI.

Diabetes was present in 859 patients (29.3%), grades 1-2 obesity in 743 (25.4%), grade 3 obesity in 399 patients (13.6%), and skin/soft tissue infections in 976 (33.3%). Most patients were aged 18-49 years (37.6%) and male (55%).

Among diabetic patients, the relative risk of an iGAS infection was 4.09 for those who were underweight (BMI < 18.5), 1.23 for the overweight (BMI 25 < 30), 3.14 for those with grade 1-2 obesity, and 15.6 for the morbidly obese. Among nondiabetics, the corresponding relative risks were 3.29, 0.87, 1.15, and 2.95, the authors reported in the poster presentation.

Dr. Langley said the next step is to look at treatment options and whether antibiotic dosing is important and “Long term, if we have a vaccine, this might be a group that needs to be targeted for vaccination.”

ID Week is a joint meeting of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, HIV Medicine Association, and Pediatric Infectious Diseases Society.

[email protected]

PHILADELPHIA – Obesity and diabetes are independent risk factors for invasive group A Streptococcus infections, with the highest risk among those with diabetes and morbid obesity.

The relative risk of invasive group A Streptococcus (iGAS) infection was 15 times higher in adults with diabetes and grade 3 morbid obesity (body mass index ≥ 40 kg/m²) than in those of normal weight, Dr. Gayle Langley reported at Infectious Diseases Week 2014.

Moreover, grades 1-2 obesity and morbid obesity increased the odds of ICU admission and death from an iGAS infection in multivariable logistic regression.

The adjusted odds ratios for ICU admission and death were 1.46 and 1.55 for patients with grades 1-2 obesity (BMI 30 < 40 kg/m²) and 2.07 and 1.62 for those with morbid obesity, she said.

Diabetes was not associated with an increased risk for either ICU admission (odds ratio, 1.06) or death (OR, 0.77) in the analysis.

Skin and soft tissue infections, which were significantly more common in obese and diabetic patients, appear to be driving the increased risk for iGAS in these groups, Dr. Langley of the Centers for Disease Control and Prevention said in an interview.

“Based on the literature, I’m not all that surprised because we definitely know that they are at increased risk for these skin and soft tissue infections, and that is a common manifestation of strep,” she said. “The mortality is slightly increased, but not to the extent of the incidence.”

The study was prompted by the limited number of prevention strategies for what Langley described as a “really serious infection” and by the rise in obesity and diabetes in the United States.

Data from select counties in 10 of the CDC’s Active Bacterial Core surveillance sites were used to identify 2,927 cases of 2010-2012 community onset iGAS. Cases were defined by isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis or streptococcal toxic shock syndrome in a resident in the surveillance area. Clinical data were obtained from medical records, with height and weight used to calculate BMI.

Diabetes was present in 859 patients (29.3%), grades 1-2 obesity in 743 (25.4%), grade 3 obesity in 399 patients (13.6%), and skin/soft tissue infections in 976 (33.3%). Most patients were aged 18-49 years (37.6%) and male (55%).

Among diabetic patients, the relative risk of an iGAS infection was 4.09 for those who were underweight (BMI < 18.5), 1.23 for the overweight (BMI 25 < 30), 3.14 for those with grade 1-2 obesity, and 15.6 for the morbidly obese. Among nondiabetics, the corresponding relative risks were 3.29, 0.87, 1.15, and 2.95, the authors reported in the poster presentation.

Dr. Langley said the next step is to look at treatment options and whether antibiotic dosing is important and “Long term, if we have a vaccine, this might be a group that needs to be targeted for vaccination.”

ID Week is a joint meeting of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, HIV Medicine Association, and Pediatric Infectious Diseases Society.

[email protected]

PHILADELPHIA – Obesity and diabetes are independent risk factors for invasive group A Streptococcus infections, with the highest risk among those with diabetes and morbid obesity.

The relative risk of invasive group A Streptococcus (iGAS) infection was 15 times higher in adults with diabetes and grade 3 morbid obesity (body mass index ≥ 40 kg/m²) than in those of normal weight, Dr. Gayle Langley reported at Infectious Diseases Week 2014.

Moreover, grades 1-2 obesity and morbid obesity increased the odds of ICU admission and death from an iGAS infection in multivariable logistic regression.

The adjusted odds ratios for ICU admission and death were 1.46 and 1.55 for patients with grades 1-2 obesity (BMI 30 < 40 kg/m²) and 2.07 and 1.62 for those with morbid obesity, she said.

Diabetes was not associated with an increased risk for either ICU admission (odds ratio, 1.06) or death (OR, 0.77) in the analysis.

Skin and soft tissue infections, which were significantly more common in obese and diabetic patients, appear to be driving the increased risk for iGAS in these groups, Dr. Langley of the Centers for Disease Control and Prevention said in an interview.

“Based on the literature, I’m not all that surprised because we definitely know that they are at increased risk for these skin and soft tissue infections, and that is a common manifestation of strep,” she said. “The mortality is slightly increased, but not to the extent of the incidence.”

The study was prompted by the limited number of prevention strategies for what Langley described as a “really serious infection” and by the rise in obesity and diabetes in the United States.

Data from select counties in 10 of the CDC’s Active Bacterial Core surveillance sites were used to identify 2,927 cases of 2010-2012 community onset iGAS. Cases were defined by isolation of GAS from a normally sterile site or from a wound in a patient with necrotizing fasciitis or streptococcal toxic shock syndrome in a resident in the surveillance area. Clinical data were obtained from medical records, with height and weight used to calculate BMI.

Diabetes was present in 859 patients (29.3%), grades 1-2 obesity in 743 (25.4%), grade 3 obesity in 399 patients (13.6%), and skin/soft tissue infections in 976 (33.3%). Most patients were aged 18-49 years (37.6%) and male (55%).

Among diabetic patients, the relative risk of an iGAS infection was 4.09 for those who were underweight (BMI < 18.5), 1.23 for the overweight (BMI 25 < 30), 3.14 for those with grade 1-2 obesity, and 15.6 for the morbidly obese. Among nondiabetics, the corresponding relative risks were 3.29, 0.87, 1.15, and 2.95, the authors reported in the poster presentation.

Dr. Langley said the next step is to look at treatment options and whether antibiotic dosing is important and “Long term, if we have a vaccine, this might be a group that needs to be targeted for vaccination.”

ID Week is a joint meeting of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, HIV Medicine Association, and Pediatric Infectious Diseases Society.

[email protected]