WEDNESDAY, Jan. 30 (HealthDay News) -- Challenging a recent U.S. government decision to lower the benchmark for designation as a high-volume heart transplant hospital, a new Johns Hopkins Medical Institutions study reports the benchmark should instead increase, from 10 transplants to 14 transplants a year.

The Centers for Medicare and Medicaid Services, which qualifies medical centers for federal reimbursement, recently lowered the high-volume standard from 12 to 10 heart transplants per year.

"Our results clearly demonstrate that current standards have been arbitrarily set too low," senior investigator Dr. John Conte, director of heart and lung transplantation at The Johns Hopkins Hospital, said in a prepared statement. "There is a certain threshold, a minimum numbers of surgeries needed to maintain the expertise of the entire transplant team."

Each year, more than 2,000 people have a heart transplant in the United States.

In their study, the Hopkins team noted that high-volume centers consistently show higher survival and lower complication rates. They analyzed the records of 14,401 people who had heart transplants in the United States between 1999 and 2006, and found that death rates one month and one year after transplant increased steadily at hospitals that did fewer than 14 transplants per year.

The overall average death rate one year after heart transplant was 12.6 percent. But patients had a 16 percent greater risk of dying in a hospital that did fewer than five heart transplants per year. Patients who had a transplant at hospitals that did more than 40 heart transplants a year had the best chance of surviving.

Patients at hospitals that did less than 10 heart transplants a year had an 80 percent increased risk of dying within a month, compared to less than 1 percent for patients at hospitals that did more than 40 heart transplants per year.

Death rates flattened for the majority of patients in hospitals that did 14 or more heart transplants per year, the researchers found.

Roughly a dozen hospitals in the United States, including Johns Hopkins, perform at least 20 heart transplants a year, the researchers noted.

The study was presented Tuesday at the Society of Thoracic Surgeons annual meeting, in Fort Lauderdale, Fla.

More information

The U.S. National Heart, Lung, and Blood Institute has more about heart transplantation.

WEDNESDAY, Jan. 30 (HealthDay News) -- An operation using tiny incisions to repair a potentially fatal weakness of a major heart artery has a lower death rate and better overall results than conventional surgery, according to a major new study.

"There have been a couple of randomized trials in Europe, both of which showed perioperative benefits with EVAR [endovascular aneurysm repair]," said study author Dr. Marc L. Schermerhorn, an assistant professor of surgery at Beth Israel Deaconess Medical Center in Boston. "In terms of early results, our study certainly confirmed the results of the randomized trials. We prove that those results are transferable to the U.S. Medicare population."

"Perioperative" refers to the period immediately after a procedure to repair a bulge in the abdominal aorta, the body's largest heart vessel. With conventional surgery, the weak spot is patched through a large incision in the abdomen. With endovascular repair, the weak spot is strengthened by a patch or tube threaded upward from small incisions in the groin.

The new study compiled results of 22,830 such procedures, half conventional surgery, half EVAR, in Medicare recipients. As did the earlier studies, it showed a marked difference in death rates immediately after the procedure, with the difference widening with age. For example, just 0.4 percent of people aged 67 to 69 having EVAR died following the procedure, compared to 2.5 percent of those having conventional surgery. The comparable rates for people aged 85 and older were 2.7 percent for those having EVAR, and 11.2 percent for those having conventional surgery.

The difference in death rates narrowed in the year that followed the procedures, disappearing in the fourth year after the procedure.

EVAR offers other immediate advantages, such as a shorter hospital stay -- an average of three days versus nine days for conventional surgery. And 95 percent of those having EVAR went home from the hospital rather than to a rehabilitation facility or nursing home, compared to 80 percent of people having conventional surgery, Schermerhorn said.

"If the anatomy is good, EVAR is worth considering for any age group," Schermerhorn said. The length of the aorta beneath the arteries to the kidneys must be long enough to allow the procedure, he added.

Dr. Roy Greenberg, director of endovascular research at the Cleveland Clinic, said the new study confirms "what other trials have already shown us."

However, the new study has some shortcomings that partially offset the advantage offered by such a large database, Greenberg said. The major disadvantage is that it lumps together a very diverse group of cases, "comparing patients that are not easily comparable," he explained.

"We do an intervention in these cases not because the aneurysm is bothering patients but because we believe it will prolong patients' lives," he said. "The real question is, are we prolonging patients' lives, and we can't get an answer from this data set. There are too many compounding factors."

Still, the new report "does point out the pros and cons that are very important when we talk to patients about a procedure," Greenberg said.

Dr. Joseph Coselli, chief of adult cardiac surgery at the Texas Heart Institute, concurred that the new research confirms the short-term benefits of EVAR, at least for older patients.

"The mortality rate is lower, morbidity is clearly lower and hospitalization time, blood requirements and the ability to return home or to work are certainly less than with open surgery," he said.

But some issues haven't been completely resolved, Coselli said. "Durability of EVAR is still up in the air," he said. "And there still is a group of patients on the younger end that may yet, based on current technology, require an open operation."

More information

Learn about abdominal aortic aneurysms and their treatment from the U.S. National Library of Medicine.

TUESDAY, Jan. 29 (HealthDay News) -- Small doses of the anti-clotting drug clopidogrel (Plavix) can benefit children under age 2 with heart problems, a new study says.

"We were astonished at how little of the drug they needed to reap the same benefits as adults. It was only about a fifth of the amount that we were expecting," Dr. Jennifer Li, a pediatric cardiologist at Duke University Medical Center, said in a prepared statement.

For this study, sponsored by Plavix makers Bristol-Myers Squibb and Sanofi-Aventis, Li recruited 92 children with various types of heart problems that put them at high risk of developing life-threatening blood clots.

Most of the children had hypoplastic left heart syndrome, which involves a poorly functioning small ventricle that leaves children weak and blue in color. Other children had floppy or imperfect heart valves, and one had Kawasaki disease, which causes inflammation in coronary arteries. Many were facing multiple surgeries, and three-quarters already had shunts in their hearts to keep their blood flowing properly.

The children were divided into a treatment group and a placebo group. Those in the treatment group received one of four doses of clopidogrel, ranging from .01 to .20 milligrams per kilogram of body weight per day over a period of one to four weeks.

The study found that the optimal dose for infants and toddlers up to 24 months was 0.2 milligrams per day.

Adults with an average weight of 75 kilograms -- or 165 pounds -- typically receive 75 milligrams per day of clopidogrel. When extrapolated, that would predict an optimal dose of about 1 milligram per day for children under age 2.

The findings "show that you can't simply extrapolate from what you do in adults and apply it to children," Li said.

The study was published in the Jan. 29 issue of Circulation.

More information

The Nemours Foundation has more about congenital heart defects  .

WEDESDAY, Jan. 23 (HealthDay News) -- Therapies that attack blood clots directly in the brain may benefit ischemic stroke patients who don't respond to the standard treatment using clot-busting drugs.

So says a U.S. study that was to have been presented Tuesday at the 20th annual International Symposium on Endovascular Therapy, in Hollywood, Fla.

Ischemic strokes -- which account for about 83 percent of strokes -- occur when a small clot blocks an artery in the brain and halts blood flow, according to the American Stroke Association. If the clot isn't cleared and blood flow restored, the patient will suffer permanent brain damage or death.

"Often patients who fail to improve with standard intravenous (IV) stroke therapy aren't given the chance to succeed with more advanced intra-arterial (IA) therapy, because it's thought that it won't work if IV therapy didn't, and that it will increase the risk of bleeding in the brain," study author Dr. Christopher Zylak, director of neurointerventional radiology at Sacred Heart Medical Center in Spokane, Wash., said in a prepared statement. "Our data suggest that IA therapy can be highly successful even when IV therapy doesn't work, and that the risk of bleeding is no different between the two therapies."

In IV therapy, clot-busting drugs are delivered through an intravenous device in the patient's arm. IV treatment must begin within three hours of the onset of stroke, which means patients must get to the hospital at the first signs of stroke.

IA therapy involves placing a catheter through a small incision in the patient's groin and moving the catheter through an artery all the way to the site of the blockage in the patient's brain. This enables direct delivery of clot-busting drugs to the area. Doctors also can use the catheter to insert a tiny corkscrew-like device to remove the clot.

In this study, the researchers compared 80 patients who received IV therapy and 43 patients who received IA therapy at Sacred Heart from 2004 through 2007. Some of the patients who received IA therapy had not responded to IV therapy.

Success rates of IA therapy (defined as opening up of the blocked blood vessel) were 85.7 percent in 2006 and 83.3 percent in 2007. Death rates among patients who received IA therapy were 30.8 percent in 2006 and 27.8 percent in 2007. That's half the 50 percent to 80 percent death rates published in the "natural history outcomes" of large-vessel strokes, the study authors said.

"Without any question, we definitely were able to help patients who failed IV therapy by providing IA therapy," Zylak said. "In the future, for large-vessel clots, IA therapy may well be the best direct therapy, bypassing IV therapy."

He noted that many stroke victims don't receive any treatment, because they don't recognize the signs (such as vision and speech problems, paralysis, and memory difficulties) and don't seek medical care. The sooner a stroke is treated, the more likely treatment will be successful.

"Overall, we are under-treating stroke. There are many patients who could benefit from stroke treatment who aren't getting it for various reasons," Zylak said. "Treatment therapies today are getting dramatic results. If a medical center doesn't offer the more advanced IA therapy, the patient can be taken by helicopter to a center that performs the therapy, even if IV therapy wasn't successful."

Stroke is the third leading cause of death in the United States, killing about 160,000 people a year, according to the National Stroke Association. About 750,000 people suffer from stroke annually.

More information

The Washington University School of Medicine has more about ischemic stroke  .