Prognostic Impact of Prolonged Cross-Clamp Time in Coronary Artery Bypass Grafting

BACKGROUND:The prognostic impact of cross-clamp time (XCT) in patients undergoing isolated coronary artery bypass grafting (CABG) has not been thoroughly investigated.MATERIAL AND METHODS:2957 patients who underwent on-pump isolated CABG from the prospective multicentre E-CABG study were the subjects of this analysis.RESULTS:The mean XCT in this series was 58±25minutes Cross-clamp time was >60 minutes in 1134 patients (38.3%), >75minutes in 619 patients (20.9%) and >90minutes in 296 patients (10.0%). Multivariate analysis showed that XCT was an independent predictor of 30-day mortality (p75minutes (2.9% vs. 1.7%, p=0.002, OR 3.479, 95%CI 1.609-7.520). Analysis of 428 propensity score matched pairs showed that XCT >75minutes was associated with significantly increased risk of early mortality, prolonged use of inotropes, postoperative use of intra-aortic balloon pump, use of extracorporeal membrane oxygenation, atrial fibrillation, prolonged stay in the intensive care unit and of composite major adverse events.CONCLUSIONS:Isolated CABG is currently performed with prolonged XCT in a significant number of patients and this seems to be a determinant of poor early outcome.</p

Anticoagulation or antiplatelet therapy of bioprosthetic heart valves recipients: an unresolved issue.

Improvements in the performance and longevity of biological valve prostheses have steadily increased their rates of implantation in recent years. Aortic bioprostheses, which are commonly used in the elderly or when the risks of anticoagulating are high, have generally been associated with low rates of long-term complications. Freedom from anticoagulation, therefore, represents the main theoretical advantage of biological, compared with mechanical, aortic prostheses. While a variety of anticoagulant and antiplatelet drug regimens have been described, a precise antithrombotic protocol for the early postoperative period after bioprosthetic aortic valve replacement has not been developed. There are also important differences between the international guidelines published. This review examines the clinical evidence concerning the use of vitamin K antagonist and antiplatelet therapy in the early management of the antithrombotic complications after bioprosthetic aortic valve replacement

Anticoagulation or antiplatelet therapy of bioprosthetic heart valves recipients: an unresolved issue

Improvements in the performance and longevity of biological valve prostheses have steadily increased their rates of implantation in recent years. Aortic bioprostheses, which are commonly used in the elderly or when the risks of anticoagulating are high, have generally been associated with low rates of long-term complications. Freedom from anticoagulation, therefore, represents the main theoretical advantage of biological, compared with mechanical, aortic prostheses. While a variety of anticoagulant and antiplatelet drug regimens have been described, a precise antithrombotic protocol for the early postoperative period after bioprosthetic aortic valve replacement has not been developed. There are also important differences between the international guidelines published. This review examines the clinical evidence concerning the use of vitamin K antagonist and antiplatelet therapy in the early management of the antithrombotic complications after bioprosthetic aortic valve replacement

Fibrillin-1 impairment enhances blood-brain barrier permeability and xanthoma formation in brains of apolipoprotein E-deficient mice.

We recently reported that apolipoprotein E (ApoE)-deficient mice with a mutation in the fibrillin-1 gene (ApoE(-/-)Fbn1(C1039G+/-)) develop accelerated atherosclerosis with enhanced inflammation, atherosclerotic plaque rupture, myocardial infarction and sudden death. In the brain, fibrillin-1 functions as an attachment protein in the basement membrane, providing structural support to the blood-brain barrier (BBB). Here, we investigated whether fibrillin-1 impairment affects the permeability of the BBB proper and the blood-cerebrospinal fluid barrier (BCSFB), and whether this leads to the accelerated accumulation of lipids (xanthomas) in the brain. ApoE(-/-) (n=61) and ApoE(-/-)Fbn1(C1039G+/-) (n=73) mice were fed a Western-type diet (WD). After 14 weeks WD, a significantly higher permeability of the BBB was observed in ApoE(-/-)Fbn1(C1039G+/-) mice compared to age-matched ApoE(-/-) mice. This was accompanied by leukocyte infiltration, enhanced expression of pro-inflammatory cytokines, matrix metalloproteinases and transforming growth factor-β, and by decreased expression of tight junction proteins claudin-5 and occludin. After 20 weeks WD, 83% of ApoE(-/-)Fbn1(C1039G+/-) mice showed xanthomas in the brain, compared to 23% of their ApoE(-/-) littermates. Xanthomas were mainly located in fibrillin-1-rich regions, such as the choroid plexus and the neocortex. Our findings demonstrate that dysfunctional fibrillin-1 impairs BBB/BCSFB integrity, facilitating peripheral leukocyte infiltration, which further degrades the BBB/BCSFB. As a consequence, lipoproteins can enter the brain, resulting in accelerated formation of xanthoma