Aorto-cardiac fistula etiology, presentation, and management: A systematic review.

BACKGROUND: Aorto-cardiac fistulae are a rare but increasingly reported entity, and data are scarce. METHOD: The authors performed a systematic review of ACFs to characterize the underlying etiology, clinical presentation, and compare outcomes of treatment strategies. RESULTS: 3,733 publications were identified in the search. Of those, 292 studies including 300 patients were included. Etiology of ACFs was 38% iatrogenic, 25% infectious, 14% traumatic, and 15% due to other causes. Most patients (74%) presented with heart failure. Common locations were aortic-right atrium (37%), and aortic-pulmonary artery (25%). The majority of patients (71%) were treated surgically, while 13% were treated percutaneously, and 16% were treated conservatively. Patients who were managed conservatively had a higher mortality than those treated with invasive closure (53% vs. 12% vs. 3%, p = <0.00001). CONCLUSIONS: This systematic review sheds light on this highly morbid condition. Once recognized, fistula closure appears to be superior to conservative management.

Meta-Analysis of Outcomes of Transcatheter Aortic Valve Implantation Among Patients With Low Gradient Severe Aortic Stenosis.

Transcatheter aortic valve implantation (TAVI) has emerged as an effective therapy for patients with severe aortic stenosis (AS). However, data on TAVI outcomes in patients with low gradient (LG) AS are limited. We performed a meta-analysis of studies comparing TAVI outcomes between patients with classic high gradient (HG) and LG AS through November 2018. The 30-day mortality, mid-term all-cause, and cardiovascular mortality at maximum follow-up were compared between patients with HG and LG AS (Pairwise meta-analysis), and between the three distinct groups of AS including HG, paradoxical low-flow low-gradient and low gradient with reduced ejection fraction (rEF-LG) (Network meta-analysis). Nineteen studies (n = 27,204 patients) met the inclusion criteria. The HG group had less 30-day, mid-term all-cause and cardiovascular mortality compared with the low-gradient AS group overall, (6% vs 7.5%, OR 0.76, 95% CI 0.66 to 0.87, I2 = 18%), (21% vs 29%, OR 0.59, 95% CI 0.52 to 0.67, I2 = 62%), and (12.6% vs 18.7%, OR 0.61, 95% CI 0.49 to 0.76, I2 = 62%), respectively, p <0.0001. These outcomes were confirmed in a trial sequential analysis in which the cumulative Z-curve crossed the conventional test boundary as well as the trial sequential monitoring boundary for all outcomes. The network meta-analysis revealed that patients with rEF-LG had similar outcomes to those with pLFLG, and both had worse outcomes than patients with classic HG AS. In conclusion patients with classic HG have better 30-day mortality, mid-term all-cause and cardiovascular mortality compared with LG patients following TAVI. Among patients with LG severe AS, TAVI outcomes were similar in patients with rEF-LG and pLFLG.

Effect of Multidisciplinary Case Conferences on Physician Decision Making: Breast Diagnostic Rounds.

PURPOSE: To evaluate the utility of multidisciplinary case conferences (MCCs) on physician decision making in benign and malignant breast disease management. METHODS:  Patients with interesting or challenging diagnostic or management issues were discussed at biweekly diagnostic breast MCCs. Prior to discussion, a clinical summary and intended management plan prior to the MCC was presented. For each case, diagnostic images/histopathology were centrally reviewed after which group discussion achieved a management consensus which was documented prospectively. Initial management plans were compared to the post-MCC consensus. A change in a management plan was defined as a consensus plan different from the pre-MCC plan or no definite plan prior to the MCC. RESULTS:  From November 2014 to December 2015, 76 patients (43 malignant and 33 benign diagnoses) were discussed in 19 MCCs. All cases presented resulted in a consensus management recommendation. Thirty-one case discussions (41%) resulted in a changed management plan (20 malignant and 11 benign diagnoses). Management changes included avoidance of immediate surgery (9% of cases), change in the type of surgery (5%), non-invasive investigation to invasive/surgical intervention (7%), and detection of a new suspicious lesion (1%). CONCLUSION: MCCs had a substantial impact on physician decision making. Management plans changed in 41% of cases presented, the majority due to new/clarified diagnostic information. Presentation of cases at MCCs should be encouraged, especially for challenging diagnostic or management issues regarding malignant or benign breast diagnoses.

Neoadjuvant Chemotherapy for Breast Cancer, Is Practice Changing? A Population-Based Review of Current Surgical Trends.

INTRODUCTION: Neoadjuvant chemotherapy in breast cancer is used to downstage locally advanced and inoperable tumors. Expanded benefits of neoadjuvant chemotherapy include downstaging of tumors to allow breast-conserving surgery (BCS) and assessment of in vivo tumor response. We sought to identify patterns and predictors of neoadjuvant chemotherapy use to determine if this has translated into population-level clinical practice. METHODS: All patients undergoing surgery for invasive breast cancer between January 2012 and June 2014 were identified from our provincial synoptic operating room database. Data regarding patient demographics, hospital, operating surgeon, preoperative tumor characteristics, neoadjuvant treatment, and type of surgery performed were collected. Descriptive statistics and multivariable analysis were used to identify predictors of neoadjuvant chemotherapy. RESULTS: A total of 4186 patients were identified, 363 (8.53%) of whom underwent neoadjuvant chemotherapy. A significant increase was seen in the use of neoadjuvant chemotherapy over time. In multivariable analysis, neoadjuvant chemotherapy was associated with prechemotherapy tumor size, multicentricity, lymph node positivity, and decreasing patient age. In addition, there was significant variability in neoadjuvant chemotherapy use between operating surgeons. Of those patients who underwent neoadjuvant chemotherapy, 68.9% were not pretreatment candidates for BCS. At the time of definitive surgery, 72.1% had mastectomy, with 18.7% opting for contralateral prophylactic mastectomy. As reported, this was due to the tumor being advanced/too large (50.4%), patient preference (12.6%), multicentricity (8.8%) and margins, genetics, and previous radiotherapy (4%). CONCLUSIONS: A significant increase in the use of neoadjuvant chemotherapy over time was identified, and treatment with mastectomy as definitive surgical management remained high. There was significant variability in neoadjuvant chemotherapy use by the operating surgeons, in addition to factors generally associated with more locally advanced/aggressive tumors.