Glycated hemoglobin and the risk of sternal wound infection after adult cardiac surgery:a systematic review and meta-analysis

Abstract Increased glycated hemoglobin (HbA1c) has been shown to increase the risk of mortality, myocardial infarction, and stroke after cardiac surgery, whereas its impact on the development of sternal wound infection (SWI) is less clear. A systematic review and meta-analysis were performed to evaluate the impact of preoperative HbA1c levels on the occurrence of SWI after adult cardiac surgery. Fourteen studies including 17,609 patients fulfilled the inclusion criteria and were included in this analysis. Diagnostic test meta-analysis of studies evaluating baseline HbA1c cut-off values ranging from 6% to 7% DCCT units (42–53 mmol/mol IFCC units) showed that the diagnostic odds ratio for deep SWI was 3.02 (95% confidence interval [CI] 2.10–4.35), while the diagnostic odds ratio for any SWI was 2.81 (95% CI 2.02–3.93). Binary meta-analysis confirmed that baseline HbA1c cut-off values ranging from 6% to 7% increased the risk for deep SWI (pooled incidence 2.7% vs 0.8%, risk ratio [RR] 3.01, 95% CI 2.32–3.90, I² 0%). Six studies included only diabetics and their pooled RR for deep SWI was 2.94 (1.59–5.45, I² 0%). Nine studies evaluated an HbA1c cut-off value of 7% and their RR for deep SWI was 3.22 (95% CI 2.38–4.37, I² 0%). The RR for any SWI was 2.92 (95% CI 2.42–3.53, I² 0%). This pooled analysis showed that the risk of SWI is substantially increased when preoperative HbA1c levels are over 6–7%. Future studies should evaluate whether postponing surgery for optimization of the glycemic control can reduce the risk of SWI in patients with increased levels of HbA1c

The effect of preoperative anemia on the outcome after coronary surgery

Abstract Background: Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. Since anemia is ultimately treated with red blood cell transfusions, we investigated the independent impact of anemia and transfusion on the outcome after coronary artery bypass grafting (CABG). Methods: This study included 2761 consecutive patients who underwent isolated CABG. Anemia was defined as hemoglobin <12.0 g/dL in women and <13.0 g/dL in men. The main outcomes were 30-day and late mortality. Results: Patients with preoperative anemia had an increased prevalence of significant comorbidities and were associated with higher unadjusted risk of early and late adverse events. Propensity score matching resulted in 560 pairs with similar baseline and operative characteristics. In these matched pairs, anemic patients had an increased risk of late all-cause death (P = 0.047) and acute kidney injury (P < 0.0001). However, when adjusted for the severity of perioperative bleeding, preoperative anemia was not associated with an increased mortality risk (HR 1.10, 95% CI 0.86–1.39). Instead, this regression model showed that the European CABG registry (E-CABG) bleeding classification was an independent predictor of late mortality (compared to grade 0: grade 1, HR 1.93, 95% CI 1.37–2.73, grade 2, HR 2.19, 95% CI 1.50–3.18, grade 3, HR 5.59, 95% CI 3.34–9.39, P < 0.0001). Conclusions: When adjusted for important baseline characteristics and operative factors as well as for the severity of perioperative bleeding and the amount of transfused blood products, anemia was not associated with an increased risk of adverse events. Increased exposure to blood transfusion among anemic patients may be the determinant of their poorer late survival

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation:a systematic review and meta-analysis

Abstract One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08–1.45, I2 0%) and major bleeding (RR 1.17, 95%CI 1.08–1.27, I2 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients

Control angiography for perioperative myocardial Ischemia after coronary surgery:meta-analysis

Abstract Background: Perioperative myocardial ischemia (PMI) in patients undergoing coronary artery bypass grafting (CABG) is associated with poor outcome. The aim of this study was to pool the available data on the outcome after control angiography and repeat revascularization in patients with perioperative myocardial ischemia (PMI) after coronary artery bypass grafting (CABG). Methods: A literature review was performed through PubMed, Scopus, ScienceDirect and Google Scholar to identify studies published since 1990 evaluating the outcome of PMI after CABG. Results: Nine studies included 1104 patients with PMI after CABG and 1056 of them underwent control angiography early after CABG. Pooled early mortality after reoperation for PMI without control angiography was 43.6% (95%CI 29.7–57.6%) and 79.8% of them (95%CI 64.4–95.2%) had an acute graft failure detected at reoperation. Among patients who underwent control angiography for PMI, 31.7% had a negative finding at angiography (95%CI 25.6–37.8%) and 62.1% had an acute graft failure (95%CI 56.6–67.6%). Repeat revascularization was performed after early control angiography in 46.3% of patients (95%CI 39.9–52.6%; 54.2% underwent repeat surgical revascularization; 45.8% underwent percutaneous coronary intervention). Pooled early mortality after control angiography with or without repeat revascularization was 8.9% (95%CI 6.7–11.1%). Three studies reported on early mortality rates which did not differ between repeat surgical revascularization and PCI (11.7% vs. 9.2%, respectively; risk ratio 1.45, 95%CI 0.67–3.11). In these three series, early mortality after conservative treatment was 5.9% (95%CI 3.6–8.2%). Conclusions: Control angiography seems to be a valid life-saving strategy to guide repeat revascularization in hemodynamically stable patients suffering PMI after CABG

Impact of high-risk features on outcome of acute type B aortic dissection

Abstract Background: Acute type B aortic dissection (TBAD) is a severe condition associated with significant morbidity and mortality. The optimal classification and treatment strategy of TBAD remain controversial and inconsistent. Methods: This analysis includes patients treated for acute TBAD at the Helsinki University Hospital, Finland between 2007 and 2019. The endpoints were early and late mortality, intervention of the aorta, and a composite of death and aortic intervention in uncomplicated patients and high-risk patients. Results: This study included 162 consecutive TBAD patients (27.8% females), 114 in the high-risk group and 48 in the uncomplicated group, with a mean age of 67.6 ± 13.9 years. Intramural hematoma was reported in 63 cases (38.9%). The mean follow-up was 5.1 ± 3.9 years. In-hospital/30-day mortality (n = 4; 3.5%) occurred solely in the high-risk group (P = 0.32). Additionally, TBAD-related adverse events (n = 23; 20.2%) were observed only in the high-risk group (P < 0.001). The cumulative incidences of the composite TBAD outcome with non–TBAD-related death as a competing risk were 6.6% (95% CI, 1.7%–16.5%) in the uncomplicated group and 29.5% (95% CI, 21.1%–38.3%) in the high-risk group at 5 years and 6.6% (95% CI, 1.7%–16.5%) and 33.0% (95% CI, 23.7%–42.6%) at 10 years (P = 0.001, Gray test). Extracardiac arteriopathy (subdistribution hazard ratio [SHR], 2.61; 95% CI, 1.08–6.27) and coronary artery disease (SHR, 2.24; 95% CI, 1.07–4.71) were risk factors for adverse aortic-related events in univariable competing-risk regression analysis. Conclusions: Recognition of risk factors underlying adverse events related to TBAD is essential because the disease progression impacts both early and late outcomes. Early aortic repair in high-risk TBAD may reduce long-term morbidity and mortality

Effectiveness of only aspirin or clopidogrel following percutaneous left atrial appendage closure

Abstract Percutaneous left atrial appendage closure (LAAC) offers a feasible option for stroke prevention in patients with atrial fibrillation (AF), but the optimal antithrombotic treatment strategy for patients with strict contraindications to oral anticoagulation (OAC) remains uncertain. We sought to evaluate short- and long-term outcome after percutaneous LAAC in these very patients discharged on single antiplatelet therapy (SAPT) alone. All consenting AF patients who underwent LAAC from February 2009 to August 2018 in Turku University Hospital, Finland, were enrolled into a prospectively maintained registry. Only patients discharged on SAPT alone were considered for the present analysis. Patients were prospectively followed up to 5 years. The primary end points were thromboembolic event (stroke, transient ischemic attack, or systemic embolism) and intracranial bleeding. Of the 165 LAAC patients, 81 patients (mean age 75 ± 7 years; 44% women; CHA₂DS₂-VASc 4.8 ± 1.4; HAS-BLED 3.2 ± 0.8) were discharged on SAPT only (77 with aspirin 100 mg) after successful LAAC using Amplatzer devices. The duration of SAPT was ≤6 months in 61 (75%) patients. The most common contraindication to OAC was previous intracranial bleeding in 48 (59%) patients. During a mean follow-up of 2.9 years, there were 6 thromboembolic events (2.7 of 100 patient-years; 73% lower-than-predicted rate of thromboembolism). Eight patients (3.6 of 100 patient-years) had a major bleeding event after discharge, and 4 patients had intracerebral bleeding (1.7 of 100 patient-years). At 6-month landmark analysis, freedom from thromboembolism and intracranial bleeding at 3-year follow-up was similar in those with discontinued and life-long SAPT (95.1% vs 88.9% and 97.6% vs 91.7%, respectively). In conclusion, long-term outcome is satisfactory after LAAC in selected AF patients with strict contraindications to OAC receiving short-term SAPT. However, adverse events are not infrequent during early postoperative months