Journal and News Scan

Dr Ranucci and collegues have analysed data collected about bleeding and transfusion in over 16,000 patients over a 12 year period. Where major bleeding (>900 ml in 12 hrs) occurred, mortality was increased. Other factors associated with mortality included red cell transfusion and preoperative anemia. This is further evidence of the harmful effects of bleeding and its consequences. It supports close attention being paid to factors that can reduce bleeding - stopping drugs associated with bleeding, and use of protocols to determine and manage excessive blood loss and reduce exposure to blood products.

Yang JH et al. – Limited data are available on comparing the clinical outcomes of coronary artery bypass grafting (CABG) and drug–eluting stent (DES) implantation in patients with reduced left ventricular systolic function in the DES era. DES implantation provides comparable long–term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.

Methods

From January 2003 to December 2010, 953 patients with reduced left ventricular systolic function, defined as a left ventricular ejection fraction <50%, who had undergone percutaneous coronary intervention with DESs (n = 402) or CABG (n = 551) were enrolled in a retrospective, observational registry.

After propensity score matching, the long-term cumulative rate of death was not significantly different between the 2 groups (DES vs CABG 21.3% vs 19.1%; adjusted hazard ratio 1.23, 95% confidence interval 0.57 to 2.66, p = 0.603). However, the rate of major adverse cardiac and cerebrovascular events (35.5% vs 24.1%, adjusted hazard ratio 1.69, 95% confidence interval 1.04 to 2.77, p = 0.036) was higher in the DES group than the CABG group. This was driven by the higher incidence of repeat revascularization in the DES group (11.3% vs 4.3%, adjusted hazard ratio 3.65, 95% confidence interval 1.01 to 10.37, p = 0.018). In conclusion, DES implantation provides comparable long-term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.

. – Patients with prosthetic heart valves are at increased risk for valve thrombosis and arterial thromboembolism. Oral anticoagulation alone, or the addition of antiplatelet drugs, has been used to minimise this risk. An important issue is the effectiveness and safety of the latter strategy. This is an update of our previous review; the goal was to create a valid synthesis of all available, methodologically sound data to further assess the safety and efficacy of combined oral anticoagulant and antiplatelet therapy versus oral anticoagulant monotherapy in patients with prosthetic heart valves. Adding antiplatelet therapy, either dipyridamole or low–dose aspirin, to oral anticoagulation decreases the risk of systemic embolism or death among patients with prosthetic heart valves. The risk of major bleeding is increased with antiplatelet therapy. These results apply to patients with mechanical prosthetic valves or those with biological valves and indicators of high risk such as atrial fibrillation or prior thromboembolic events. The effectiveness and safety of low–dose aspirin (100 mg daily) appears to be similar to higher–dose aspirin and dipyridamole. In general, the quality of the included trials tended to be low, possibly reflecting the era when the majority of the trials were conducted (1970s and 1980s when trial methodology was less advanced).

Patients undergoing first time CABG using CPB were randomized to remote ischemic preconditioning (left upper arm) or control after induction of anesthetic.  The metric was myocardial injury measured by troponin levels during the first 3 postop days.  Preconditioning resulted in lower troponin levels and in lower operative mortality.