Transthyretin cardiac amyloidosis: A treatable form of heart failure with a preserved ejection fraction

Cardiac amyloidosis (CA) is considered a rare disease with poor prognosis and limited therapeutic options. However, non-biopsy diagnostic modalities as well as emerging therapies are challenging this long-held belief. Radionuclide bone scintigraphy is increasingly being used in the diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CA). As such, it is expected that the number of patients diagnosed with ATTR-CA will continue to rise. Emerging therapies decrease the progressive morbidity and mortality associated with ATTR-CA. The importance of early recognition of ATTR-CA is imperative as prompt initiation of these novel agents is essential to maximize their therapeutic potential. Herein, we outline the current approach to diagnosis of ATTR-CA and review the therapeutic management of the disease.     

Does a high Mandard score really define a poor response to chemotherapy in oesophageal adenocarcinoma?

Background A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients.Methods Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients.Results Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1–3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16–0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (−16.3 vs −7.7 cm³, p = 0.033) with no significant difference between Mandard groups.Conclusion Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.Subject terms: Oesophageal cancer, Surgical oncology     

Stage 1 acute kidney injury is independently associated with infection following cardiac surgery

ObjectivesSevere acute kidney injury (AKI) is a known risk factor for infection and mortality. However, whether stage 1 AKI is a risk factor for infection has not been evaluated in adults. We hypothesized that stage 1 AKI following cardiac surgery would independently associate with infection and mortality.MethodsIn this retrospective propensity score–matched study, we evaluated 1620 adult patients who underwent nonemergent cardiac surgery at the University of Colorado Hospital from 2011 to 2017. Patients who developed stage 1 AKI by Kidney Disease Improving Global Outcomes creatinine criteria within 72 hours of surgery were matched to patients who did not develop AKI. The primary outcome was an infection, defined as a new surgical-site infection, positive blood or urine culture, or development of pneumonia. Secondary outcomes included in-hospital mortality, stroke, and intensive care unit (ICU) and hospital length of stay (LOS).ResultsStage 1 AKI occurred in 293 patients (18.3%). Infection occurred in 20.9% of patients with stage 1 AKI compared with 8.1% in the no-AKI group (P < .001). In propensity-score matched analysis, stage 1 AKI independently associated with increased infection (odds ratio [OR]; 2.24, 95% confidence interval [CI], 1.37-3.17), ICU LOS (OR, 2.38; 95% CI, 1.71–3.31), and hospital LOS (OR, 1.30; 95% CI, 1.17-1.45).ConclusionsStage 1 AKI is independently associated with postoperative infection, ICU LOS, and hospital LOS. Treatment strategies focused on prevention, early recognition, and optimal medical management of AKI may decrease significant postoperative morbidity.     

Diagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysis

ObjectiveTo compare the diagnostic accuracy of transesophageal echocardiography (TEE) and cardiac computed tomography (CCT) in diagnosing infective endocarditis (IE).BackgroundTEE is a mainstay imaging modality for IE, while the use of CCT is becoming increasingly prevalent. Data directly comparing the diagnostic performance of these two imaging modalities for IE are limited.MethodsWe conducted a systematic review and meta-analysis of published literature in Embase, PubMed and Cochrane databases through October 1, 2020 for studies comparing diagnostic performance of CCT and TEE for the diagnosis of IE in the same patient populations. A meta-analysis of diagnostic accuracy was performed using the bivariate model based on studies that used surgical pathology as a reference standard for defining endocarditis. From a total of 10 studies included in the meta-analysis, a total of 872 patients were evaluated.ResultsThe pooled sensitivities and specificities of TEE for detecting vegetations were 96% and 83% respectively, whereas for CCT, they were 85% and 84%, respectively. In the prosthetic valve sub-group, the pooled sensitivities and specificities of TEE for detecting vegetations were 89% and 74% respectively, whereas for CCT, they were 78% and 94%, with CCT being more specific than TEE (p < 0.05). The pooled sensitivities and specificities of TEE for detecting periannular complications were 70% and 96% respectively, whereas for CCT, they were 88% and 93%, respectively. CCT showed a trend (p = 0.06) towards higher sensitivity than TEE for detection of periannular complications. The pooled sensitivities and specificities of TEE for detecting leaflet perforation were 79% and 93% respectively, whereas for CCT, they were 48% and 93% respectively, with TEE being more sensitive (p < 0.05). The two modalities also showed comparable diagnostic performance for detecting fistulae, paravalvular leaks and prosthetic valve dehiscence.ConclusionIn a contemporary comparative meta-analysis, TEE and CCT demonstrated both good diagnostic accuracy for detecting valvular involvement and complications of IE. TEE performed better for detecting leaflet defects, whereas CCT performed better in cases of prosthetic valve involvement, and showed a trend towards improved detection of periannular complications. Appropriate, complementary use of both TEE and CCT in a multimodality imaging approach in clinical practice may achieve the highest diagnostic performance.