Journal and News Scan

The authors evaluated the change in risk profile of 65097 patients who underwent CABG between 1997 and 2011 in the Veterans Affairs Surgical Quality Improvement Program (VASQIP). They found that there was a marked increase in the prevalence of obesity, diabetes, left main coronary artery disease and NYHA class. Prevalences of previous myocardial infarction, low ejection fraction and advanced angina decreased. Importantly, operative mortality decreased over time. The trends confirm the general perception of ongoing improvement in outcomes, despite a sicker and older population.

Dr. Reed et al from the Cleveland Clinic conducted this prospective study to assess whether VerifyNow point-of-care platelet testing could predict bleeding in 39 patients receiving Plavix and undergoing CABG.  Patients in higher PRU quartiles experienced smaller decreases in hematocrit and less bleeding.  By ROC analysis, a PRU threshold of ≤207 was the optimal threshold for discrimination of major bleeding during surgery, with 85% sensitivity and an 89% NPV.

Question:  Should VerifyNow platelet testing be used as a discriminator for timing of CABG rather than waiting the guideline-recommended 5 days for patients who have received Plavix?

The Columbia University group performed this retrospective review of femoral VA ECMO at their institution from 2007-2013, and analyzed short-term outcomes based on the size of the arterial cannula.  They compared two groups of patients:  those undergoing femoral cannulation with a size 17F or larger cannula versus those undergoing cannulation with a 15F cannula. Despite higher flows in the larger cannula group, at 24 hours of support there were no differences in hemodynamic or laboratory parameters or in the use of vasoactive medications.  There was also no difference in 30-day survival.  Importantly, however, there was a significant reduction in bleeding complications in the group receiving the smaller arterial cannula.

In this recently published clinical study investigators from Columbia University, New York Presbyterian Hospital evaluated the safety of Del Nido cardioplegia in high-risk CABG surgery after AMI. The comparisons are made between commonly used wshole blood cardioplegia and the Del Nido solution.  The authors report no differences in transfusion rates, length of stay, need for pharmacologic or mechanical support post pump, or 30 day mortality between the two groups. However, the investigators do report shorter cross clamp, CPB and overall operative times due to the lack of interruption inherent to standard whole blood cardioplegia, which requires re-dosing.  The investigators discuss the biochemical and metabolic changes seen in AMI and further explain the potential advantages the Del Nido solution affords in stabilizing these derangements, which may lead to improved outcomes.