Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Undiagnosed aberrant right subclavian artery: pitfall in aortic arch surgery

Selected cerebral perfusion as brain protection via right subclavian artery during aortic arch aneurysm repair adds safety, but may be jeopardized by aortic arch anomalies not readily recognized preoperatively. We describe a case of transverse aortic arch aneurysm repair where an undiagnosed aberrant right subclavian artery was cannulated for selective brain protection

Aortic arch replacement using a four-branched aortic arch graft

Surgical repair for aortic arch aneurysms is associated with considerable mortality and morbidity. Adequate brain protection is essential. Experience of aortic arch repair in six patients using a four-branched arch graft is described. There were two emergency and three reoperations. One patient had ruptured aneurysm. Hypothermic cardiopulmonary bypass (18-22 degrees C) was employed. A four-branched polymer albumin-coated arch graft was used. The fourth branch of the graft was used for secondary arterial cannulation to ensure continuous brain circulation. One hospital death occurred. No permanent neurological event occurred. The four-branched arch graft facilitates fashioning arch branch anastomoses and provides better brain protection

Endovascular repair using vein-covered stents in the carotid artery bifurcation

The treatment of a bleeding carotid artery pseudoaneurysm in a patient using endovascular repair is described. Vein-covered stents were successfully employed. There were no neurological complications and no recurrent bleeding during 8 months follow up and carotid artery continuity was achieved. Stents covered with saphenous vein may be considered a treatment option for endovascular repair of pseudoaneurysm of the carotid artery

Regional extra-corporeal circulation to protect transplanted kidney and pancreas from ischemia during vascular reconstruction

The development of severe aorto-ilio-femoral atherosclerotic disease in a patient with a previous double transplantation, kidney and pancreas, is a major surgical challenge. The transplanted organs have to be protected from extensive ischemia during the vascular reconstructive procedure and achieve optimal revascularization. The surgical management of a complex case where regional extra-corporeal circulation was used to protect transplanted pancreas and kidney during aorto-bifemoral vascular grafting in a 39 yr old diabetic patient is described. Regional femoro-femoral extra-corporeal circulation with an oxygenator is a safe technique that allows time for the proximal revascularization, minimizes the warm organ ischemia time and results in preservation of organ function

Impact of Double Internal Thoracic Artery Grafts on Long-Term Outcomes in Coronary Artery Bypass Grafting

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983–1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n=139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n=173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications

Obtaining a superficial femoral artery graft in adolescents and children with the deep femoral artery transposition

A new technique to obtain a segment of the superficial femoral artery as an arterial conduit in young patients while an unobstructed peripheral blood flow is maintained by superficial femoral artery-deep femoral artery transposition is illustrated with two clinical examples. The explanted arterial autograft requires no replacement by another graft and provides a conduit of up to 10 cm in length. Excellent results were achieved in both patients at 1 year. This technique is recommended instead of saphenous vein conduits in very young patients because of the risk for late vein degeneration

Original articleImpact of the time to reperfusion on early outcomes in patients with acute myocardial infarction undergoing primary angioplasty

Background: The ACC/AHA guidelines for management of patients with ST-elevation myocardial infarction (STEMI) have recommended primary PCI (pPCI) as the preferred reperfusion therapy, when it can be performed in a timely fashion, within 90-110 min from the first contact with medical personnel. The impact of treatment delays on outcomes in patients undergoing pPCI has been controversial. Aim: To evaluate the impact of time delays on in-hospital mortality and on the frequency of cardiac events during 30 days after STEMI. Methods: 1723 patients were stratified on the basis of their time delays: from symptom onset until balloon inflation. The patients were divided into 4 groups: group 1 (311 patients) &#8211; time from symptom onset 360 min. Results: The median time delay was 268.5&#177;206 min, the median door to balloon time was 36.12&#177;11.2 min. The patients with longer time delays (group 4) were older, more often were women, and had a higher frequency of diabetes, anterior MI and Killip class 4. During hospitalisation, 70 (4.1%) patients died. In-hospital mortality was significantly higher in group 4 (13.6%) than in other groups. Complications of STEMI such as cardiogenic shock considerably influenced mortality (45.6%). During a 30-day follow- -up, the patients with cardiogenic shock and the elderly had an increased risk of cardiac events. Also, time delays >360 min and failed pPTCA were independent adverse risk factors in multivariate regression analysis. Conclusion: Delays in time to pPCI have an impact on outcomes, especially in those treated >6 hours from the onset of symptoms.Wstęp: Wytyczne postępowania ACC/AHA oraz ESC zalecają pierwotną przezskórną interwencję wieńcową (pPCI) u chorych z zawałem serca z uniesieniem odcinka ST (STEMI) jako leczenie reperfuzyjne pierwszego rzutu, jeżeli można ją wykonać w czasie 90&#8211;110 min od pierwszego kontaktu z personelem medycznym. W grupach chorych leczonych metodą pPCI oceny dotyczące zależności między opóźnieniem reperfuzji a przeżyciem nie są nadal jednoznaczne. Cel: Analiza wczesnych wyników leczenia STEMI metodą pPCI z uwzględnieniem czasu, jaki upłynął od początku objawów do rozprężenia balonu, oraz identyfikacja najważniejszych zmiennych wpływających na ryzyko wystąpienia złożonego punktu końcowego (zgonu, ponownego zawału serca czy udaru) we wczesnej, 30-dniowej obserwacji. Metodyka: Badaną populację 1723 chorych podzielono na 4 grupy w zależności od czasu opóźnienia od początku bólu do pPCI. Grupa 1. to 311 chorych z opóźnieniem do 90 min, grupa 2. &#8211; 731 chorych z opóźnieniem 90&#8211;180 min, grupa 3. &#8211; 535 chorych z opóźnieniem 180&#8211;360 min, grupa 4. &#8211; 146 chorych z opóźnieniem >360 min. Wyniki: Chorych przewożonych bezpośrednio z miejsca zamieszkania przez zespół pogotowia ratunkowego było 1175 (68,2%), natomiast 548 (31,8%) chorych transportowano z innych szpitali położonych zarówno w granicach miasta, jak i województwa. Średni czas transportu wynosił 54,5&#177;17,8 min. Dla całej badanej populacji średni czas opóźnienia reperfuzji (od początku bólu do pPCI) wynosił 268,5&#177;206 min, natomiast czas opóźnienia wewnątrzszpitalnego (drzwi-balon) wynosił 36,12&#177;11,2 min. Nie stwierdzono istotnych różnic między badanymi grupami co do czasu opóźnienia wewnątrzszpitalnego. Na podstawie analizy danych demograficznych oraz klinicznych stwierdzono, że grupa 4. (z najdłuższym opóźnieniem od początku bólu) była najstarsza, przeważały w niej kobiety, częściej występowała u nich cukrzyca, zawał ściany przedniej oraz objawy niewydolności, w tym wstrząs kardiogenny. W tej grupie istotnie częściej (p 6 godz. 3) Pozostałe czynniki związane z wystąpieniem złożonego punktu końcowego to wstrząs, wiek >75 lat oraz skuteczność PCI