Temporal trends and outcomes in aortic and mitral valve surgery in Finland

Aortic valve surgery is the most common type of heart valve surgery in western countries. The main causes for aortic valve surgery are aortic valve stenosis and regurgitation. Mitral valve regurgitation is the most common cause for mitral valve surgery, as mitral stenosis is rare. The proportion of mitral valve repairs has increased during the last decades. It is currently the primary choice for treating mitral valve disease of all etiologies. Cardiac surgery patients have sex-depended differences as to type of surgery and outcome. Women are usually older by the time of surgery, and the comorbidity burden differs between sexes. Results on outcome are conflicting. Thromboembolic prophylaxis is indicated for the first three months after biologic valve replacement. However, often the need for anticoagulation is long-term due to other conditions that increase the risk of thromboembolic complications. The aim of this study was to elucidate nationwide trends in mitral and aortic valve surgery in Finland. We also studied the sex differences in long-term outcomes after an aortic valve replacement procedure, and the prevalence and type of longterm oral anticoagulation treatment and their association with complications and death in patients who have undergone biological aortic valve replacement. We found that the proportion of mitral valve repair surgery and the use of bioprosthetic valves have increased. Short- and long-term mortality after mitral valve surgery has decreased. The basic characteristics of aortic valve patients have changed: patients are older, the proportion of women has decreased, and patients have markedly more comorbidities. The use of bioprosthetic aortic valves has increased and short-term mortality has improved while long-term mortality has remained unchanged. Sex is not an independent risk factor for long-term mortality after surgical aortic valve replacement. However, male-sex was associated with higher risk of bleeding, infective endocarditis, and re-surgery. The use of oral anticoagulation after biologic aortic valve replacement appears to be associated with decreased risk of death and increased risk of stroke.Aortta- ja mitraaliläppäkirurgian pitkän aikavälin muutokset Suomessa Aorttaläppäkirurgia on tavallisin sydänkirurgian muoto länsimaissa. Tavallisimmat syyt aorttaläppäkirurgialle ovat aorttaläpän ahtauma ja vuoto. Mitraaliläppäkirurgian tavallisin syy on mirtaaliläpän vuoto. Mitraaliläpän ahtauma on nykyään harvinainen. Mitraaliläpän korjausleikkauksien osuus on noussut viimeisien vuosikymmenten aikana. Se on tällä hetkellä ensisijainen mitraaliläpän vajaatoiminnan hoitomuoto riippumatta aiheuttajasta. Sydänkirurgisilla potilailla tiedetään olevan sukupuolesta riippuvaisia eroja. Naiset ovat yleensä vanhempia leikkauksen aikaan, ja perussairauksien aiheuttama taakka eroaa sukupuolten välillä. Tulokset ennusteesta ovat vaihtelevia. Tromboosiprofylaksiaa suositellaan ensimmäisen kolmen kuukauden ajaksi biologisen aorttatekoläppäleikkauksen jälkeen. Kuitenkin antikoagulaation tarve on usein pitkäaikainen muiden tromboembolisia komplikaatioita aiheuttavien sairauksien johdosta. Tutkimuksemme tavoitteena oli selvittää mitraaliläpän korjaus- ja tekoläppäleikkauksen sekä aorttatekoläppäleikkauksen maanlaajuisia pitkäaikaismuutoksia ja -ennustetta Suomessa. Tavoitteena oli lisäksi tutkia sukupuolieroja pitkäaikaisennusteessa aorttatekoläppäleikkauksen jälkeen. Näiden lisäksi tutkimme pitkäaikaisantikoagulaation esiintyvyyttä ja tyyppiä biologisen aorttatekoläppäleikkauksen jälkeen. Totesimme, että biologisten läppäproteesien käyttö ja mitraaliläpän korjausleikkausten määrä lisääntyi. Mitraaliläppäkirurgian lyhyt- ja pitkäaikaiskuolleisuus on laskenut. Aorttaläppäpotilaiden taustaominaisuudet muuttuivat seuranta-aikana: potilaat ovat vanhempia, naisten osuus pieneni ja perussairauksien määrä kasvoi. Biologisten aorttaläppäproteesien käyttö lisääntyi, lyhytaikaiskuolleisuus vähentyi ja pitkäaikaisennuste pysyi ennallaan. Sukupuoli ei ole itsenäinen pitkäaikaiskuolleisuuden riskitekijä aorttatekoläppäleikkauksen jälkeen. Miehillä on suurentunut riski vuotokomplikaatioille, infektiiviselle endokardiitille ja uusintaleikkaukselle. Suun kautta otettavien antikoagulanttien pitkäaikaiskäyttö aortan biologisen tekoläppäleikkauksen jälkeen vaikuttaisi liittyvän vähentyneeseen kuolemariskiin ja lisääntyneeseen aivohalvausriskiin

Preoperative cardiac assessment in liver transplant candidates

New and extended indications, older age, higher cardiovascular risk, and the long-standing cirrhosis-associated complications mandate specific skills for an appropriate preoperative assessment of the liver transplant (LT) candidate. The incidence of cardiac diseases (dysrhythmias, cardiomyopathies, coronary artery disease, valvular heart disease) are increasing among LT recipients: however, no consensus exists among clinical practice guidelines for cardiovascular screening and risk stratification. In spite of different "transplant center-centered protocols", basic "pillars" are common (electrocardiography, baseline echocardiography, functional assessment). Owing to intrinsic limitations, yields and relevance of noninvasive stress tests, under constant scrutiny even if used, are discussed, focusing the definition of the "high risk" candidate and exploring noninvasive imaging and new forms of stress imaging. The aim is to find an appropriate and rational stepwise algorithm. The final commitment is to select the right candidate for a finite resource, the graft, able to save (and change) lives

Acute, periprocedural and longterm antithrombotic therapy in older adults

The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults. © The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved.info:eu-repo/semantics/publishedVersio

Antithrombotic Medication for Cardioembolic Stroke Prevention

Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed

Molecular Adsorbents Recirculating System (MARS): evidence and management pitfalls

published_or_final_versio

Emergency Cardiology

This fully revised and updated second edition offers practical advice on the diagnosis and management of acute cardiac conditions. Throughout the book, the authors employ an evidence-based approach to clinical practice and provide detailed guidance for day-to-day practice in a wider variety of settings-from the emergency department to intensive care and the cardiac ward. Authored by four cardiologists with extensive experience in the emergency setting, it includes the results of the most groundbreaking clinical trials. Topics include arrhythmias, acute aortic syndromes, pericarditis, and cardiac trauma

Primary Angioplasty

Medicine; Cardiolog

Aortic Valve Stenosis

Currently, aortic stenosis is the most frequent heart valve disease in developed countries and its prevalence increases with the aging of the population. Affecting 3-5 percent of persons older than 65 years of age, it makes a large personal and economical impact. The increasing number of elderly patients with aortic stenosis brings advances in all medical specialties dealing with this clinical entity. Patients previously considered too old or ill are now indicated for aortic valve replacement procedures. This book tries to cover current issues of aortic valve stenosis management with stress on new trends in diagnostics and treatment