New Oral Anticoagulants Versus Warfarin in Atrial Fibrillation After Early Postoperative Period in Patients With Bioprosthetic Aortic Valve

Background: The efficacy of novel nonvitamin K antagonist oral anticoagulants (NOACs) in nonvalvular atrial fibrillation (AF) to prevent stroke is well assessed, but NOACs use in AF that occurs after bioprosthetic aortic valve replacement (AVR) is not endorsed. This retrospective real-world study evaluated the efficacy and safety of NOACs prescribed no earlier than 4 months after AVR as an alternative to warfarin in patients with AF. Methods: We pooled 1032 patients from the databases of 5 centers. Ischemic/embolic events and major bleeding rates were compared between 340 patients assuming NOACs and 692 prescribed warfarin. Propensity score matching was performed to avoid the bias between groups. Results: The NOACs vs warfarin embolic/ischemic rate was 13.5% (46 of 340) vs 22.7% (157 of 692), respectively, (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.37-0.75; P < .001), and the incidence rate was 3.7% vs 6.9% patients/year, respectively (log-rank test P = .009). The major bleeding rate was 7.3% (25 of 340) vs 13% (90 of 692) (HR, 0.5; 95% CI, 0.33-0.84; P = .007), and the incidence rate was 2% vs 4% patients/year (log-rank test P = .002.) After propensity score matching, the NOACs vs warfarin embolic/ischemic rate was 13.1% (42 of 321) vs 21.8% (70 of 321) (HR, 0.6; 95% CI, 0.4-0.9; P = .02), and the incidence rate was 4.1% vs 6.7% patients/year (log rank test P = .01). The major bleeding rate was 7.8% (25 of /321) vs 13.7% (44 of 321) (HR, 0.5; 95% CI, 0.31-0.86; P = .01), and the incidence rate was 2.4% vs 4.2% patients/year (log-rank P = .01). Conclusions: In a real-word study, NOACs use overcomes the indications provided by guidelines. This study evidenced that NOACs use in patients who developed AF after bioprosthetic AVR was more effective in prevention of thromboembolism and safe in reduction of major bleeding events compared with warfarin

Safety of aortic aneurysm repair 8 weeks after percutaneous coronary intervention for coronary artery disease: a cohort study

Guidelines advice against dual antiplatelet therapy (DAPT) discontinuation less than 12 months after percutaneous coronary intervention with drug-eluting stents (DES-PCI). However, any delay of necessary surgery in patients with descending thoracic (DTA) or abdominal aortic aneurysm (AAA), treated by DES-PCI, increases the risk of aneurysm rupture/dissection. We evaluated the safety of 8-week waiting time between DES-PCI and endovascular aortic repair (EVAR). 1152 consecutive patients with coronary artery disease (CAD) needing elective DTA or AAA repair were enrolled and divided into two groups. Group A included 830 patients treated by DES-PCI for significant CAD who underwent surgery 8 weeks after implantation. Group B included 322 patients treated by DES-PCI at least 6 months before with no residual significant CAD and treated by elective EVAR. Groups were compared according to a composite of death, myocardial infarction, stent thrombosis, cerebrovascular events and bleeding. No aneurysm rupture/dissection occurred while waiting for surgery. Hospital averse events occurred in 6.2% (52/830) group A patients versus 6.5% (21/322) group B patients (p = 0.8). Mortality was 0.7% (6/830) in group A and 0.9% (3/322) in group B (p = 0.7). Multivariate predictors of events were triple vessel DES-PCI (p 3 stents implanted (p 30 mm (p = 0.02). Eight weeks of waiting after DES-PCI in addition to an adequate management of DAPT were safe in terms of cardiac morbidity and bleeding complications. No aneurysm rupture occurred in the interval before surgery

Status of coronary disease and results from early endovascular aneurysm repair after preventive percutaneous coronary revascularization

Background: The incidence of coronary artery disease (CAD) is high in patients with an aortic aneurysm but preoperative routine coronary angiography and preventive coronary revascularization are not recommended to reduce cardiac events in patients with severe CAD. Aim: This study evaluated the safeness and efficacy of preventive percutaneous coronary intervention (PCI) in patients with severe CAD scheduled for endovascular aneurysm repair (EVAR). Methods: All patients with descending thoracic aneurysm (DTA) or abdominal aortic aneurysm (AAA) scheduled for EVAR underwent preliminary coronary angiography. Based on coronary angiography results, 917 patients (40.7%) had significant CAD and were treated by percutaneous coronary intervention (PCI; CAD group) and 1337 patients (59.3%) were without or with mild/moderate CAD and were considered as controls (no‐CAD group). To evaluate the safeness and efficacy of preventive PCI in patients with severe CAD undergoing EVAR, groups were compared for hospital and 12‐month cardiac adverse events. Results: CAD was present in 1210 patients (53.6%): significant in 917 patients (38%) and mild to moderate in 293 patients (5.3%). Hospital and 12‐month cardiac events occurred in 15 (1.6%) and 13 (1.4%) CAD group patients and in 9 (0.7%) and 8 (0.4%) no‐CAD group patients (p = .05 and p = .08), respectively. Hospital and 12‐month cardiac deaths occurred in 3 (0.3%) and 2 (0.2%) CAD group patients and in 3 (0.2%) and 2 (0.2%) no‐CAD group patients (p = .9 and p = .9), respectively. Conclusion: The strategy to treat severe CAD preoperatively by PCI and early subsequent EVAR brings a similar outcome to that in patients without or with mild/ moderate CAD

First experience with sildenafil after Fontan operation: short-term outcomes.

Background We conducted a retrospective study to determine the effect of oral sildenafil administrated as monotherapy after Fontan operation in single ventricle physiology. Methods From January 2008 to March 2012, during two different periods, a total of 30 pediatric patients undergoing Fontan operation by extracardiac conduit were included in this study. Thirteen patients were in the sildenafil group and exclusively treated with sildenafil given at the dose of 0.35 mg/kg through a nasogastric tube and then orally every 4 h, at the start of cardiopulmonary bypass and for the first postoperative week; then we reduced and discontinued the therapy. The other 17 patients were in the control group. No other vasodilator was administered in both groups. We analyzed intraoperative and postoperative outcomes of sildenafil administration. Results There were no differences in mortality or operative time. The total and relative drainage loss was lower in the sildenafil group (PU0.0003 and 0.0045). The hemodynamic parameters showed a better condition in the sildenafil group, with a lower mean pulmonary artery pressure (mPAP) (PU0.0001) and better mPAP to mean systemic blood pressure (mSBP) ratio (PU0.0043), whereas there was no difference in peripheral oxygen saturation (PU0.31). The sidenafil group patients showed other additional positive differences as well as lower inotropic score (PU0.0005) and intubation time (PU0.0004). No complications related to the use of sildenafil were noted in any of the children studied. Conclusion This initial experience provides evidence that sildenafil may be used in postoperative Fontan operation with positive effectiveness

Tranexamic acid therapy in pediatric cardiac surgery:a single center study

Background: We conducted a retrospective study of cyanotic and acyanotic patients undergoing cardiopulmonary bypass to determine the effect of tranexamic acid on blood loss and blood products administered during the operation in pediatric cardiac surgery. Methods: From January 2008 to December 2011, during 2 different periods, a total of 231 pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (123 cyanotic, 108 acyanotic) were included in this study. A total of 104 patients were in the antifibrinolytic group and exclusively treated with tranexamic acid that was given as a bolus of 20 mg/kg-1 after anesthetic induction and 20 mg/kg-1 after protamine. The other 127 patients were in the control group. We analyzed intraoperative and postoperative outcomes of tranexamic acid administration. Results: There were no differences in mortality or operative time, but blood loss in 48 hours was greater in the control group (p = 0.0012). A significant difference was found in the amount of intraoperative erythrocyte concentrate transfused (140 ± 55 vs 170 ± 78 mL, p = 0.0011) but not in number. The number and amount of erythrocyte concentrate transfused in the first 48 postoperative hours were also greater in the control group (45 vs 77 patients, p = 0.012; 100 ± 40 vs 120 ± 55 mL, p = 0.0022). There were not many differences in the effect of tranexamic acid between the cyanotic and acyanotic subgroup. Conclusions: This retrospective study provides evidence that tranexamic acid may be used in the field of congenital cardiac surgery effectively

Development of a risk score for early saphenous vein graft failure: An individual patient data meta-analysis

Objectives: Early saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery). Methods: Published literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively. Results: In aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716). Conclusions: From a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies