Background Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery to left anterior descending bypass with percutaneous coronary intervention of non-left ...anterior descending vessels. Its safety and effectiveness compared with conventional CABG have been under studied. Study Design Patients with multivessel disease and/or left main disease who underwent HCR at a US academic center between October 2003 and September 2013 were included. These patients were matched 1:3 to patients treated with CABG using a propensity-score matching algorithm. Conditional logistic regression and Cox regression analyses stratified on matched pairs were performed to evaluate the adjusted association between HCR and short- and long-term outcomes. Results The 30-day composite of death, MI, or stroke after HCR and CABG was 3.3% and 3.1% (odds ratio = 1.07; 95% CI, 0.52–2.21; p = 0.85) in the matched cohort of 1,224 patients (HCR, n =306; CABG, n = 918). Hybrid coronary revascularization was associated with lower rates of in-hospital major morbidity (8.5% vs 15.5%; p = 0.005), lower blood transfusion use (21.6% vs 46.6%; p < 0.001), lower chest tube drainage (690 mL; 25th to 75th percentile: 485 to 1,050 mL vs 920 mL, 25th to 75th percentile: 710 to 1,230 mL; p < 0.001), and shorter postoperative length of stay (<5-day stay: 52.6% vs 38.1%; p = 0.001). During a 3-year follow-up period, mortality was similar after HCR and CABG (8.8% vs 10.2%; hazard ratio = 0.91; 95% CI, 0.55–1.52; p = 0.72). Subgroup analyses in patients stratified by 2-vessel, 3-vessel, left main disease, and by Society of Thoracic Surgeons risk scores rendered similar results. Conclusions The use of HCR appeared to be safe, with faster recovery and similar outcomes when compared with conventional CABG. These findings were consistent irrespective of anatomic or predicted procedural risk.
Valve-in-Valve Transcatheter Aortic Valve Implantation for Degenerated Bioprosthetic Heart Valves Holger Eggebrecht, Ulrich Schäfer, Hendrik Treede, Peter Boekstegers, Jörg Babin-Ebell, Markus ...Ferrari, Helge Möllmann, Helmut Baumgartner, Thierry Carrel, Philipp Kahlert, Philipp Lange, Thomas Walther, Raimund Erbel, Rajendra H. Mehta, Matthias Thielmann Multicenter data from 47 patients aged 64 to 97 years undergoing transfemoral (n = 25) or transapical (n = 22) valve-in-valve (viv) transcatheter aortic valve implantation (TAVI) for degenerated surgically implanted bioprosthetic heart valves were analyzed. Procedural success was obtained in all patients. Vascular access complications occurred in 6 (13%). Five (11%) patients required new pacemaker implantation. Valvular function was excellent with respect to valve competence, but increased transvalvular gradients ≥20 mm Hg were noted in 44%. Mortality at 30 days was 17% (1 procedural and 7 post-procedural deaths). Valve-in-valve TAVI can be performed with high technical success rates, acceptable post-procedural valvular function, and excellent functional improvement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective Left ventricular systolic dysfunction is associated with increased morbidity and mortality in patients undergoing cardiac surgery. The authors performed a meta-analysis investigating the ...effects of levosimendan in cardiac surgery patients with and without preoperative systolic dysfunction. Design Meta-analysis of randomized controlled trials. Setting Hospital. Participants The 1,155 patients who participated in 14 randomized controlled trials of perioperative levosimendan were included. Interventions None. Measurements and Main Results PubMed, EMBASE, the Cochrane database of clinical trials, and conference proceedings were searched for clinical trials of perioperative levosimendan in patients undergoing cardiac surgery through May 1, 2012. Studies were grouped by mean ejection fraction (EF). Those with a mean EF <40% were designated as low-EF. Pooled results demonstrated a reduction in mortality with levosimendan (risk difference RD–4.2%; 95% CI −7.2%, −1.1%; p = 0.008). Subgroup analysis showed that this benefit was confined to the low-EF studies (RD −7.0%; 95% CI −11.0%, −3.1%; p < 0.001). No benefit was observed in the preserved-EF subgroup (RD +1.1%; 95% CI −3.8%, +5.9%; p = 0.66). Significant reductions also were seen in the need for dialysis (RD −4.9%; 95% CI −8.2%, −1.6%; p = 0.003), myocardial injury (RD −5.0%; 95% CI −8.3%, −1.7%; p = 0.003), and postoperative atrial fibrillation (RD −8.1%; 95% CI −13.3%, −3.0%; p = 0.002). Conclusions Levosimendan was associated with reduced mortality and other adverse outcomes in patients undergoing cardiac surgery, and these benefits were greatest in patients with reduced EF. These data support the need for adequately powered randomized clinical trials to confirm the benefits of levosimendan in patients with reduced EF undergoing cardiac surgery.
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Gender-related differences in the incidence of bleeding and its relation to subsequent mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolysis are not ...well understood. We studied patients with STEMI receiving fibrinolysis enrolled in 6 clinical trials. Outcomes included moderate or severe bleeding defined using Global Utilization of Strategies to Open Occluded Arteries (GUSTO) criteria and adjusted 1-year mortality (excluding deaths in first 24 hours). Moderate or severe bleeding was 1.9-fold higher in women compared to men (13.3% vs 7.1%, p <0.0001). Bleeding remained higher in women even after adjustment for baseline differences (odd ratios 1.52, 95% confidence interval CI 1.42 to 1.62). In fact, female gender was second most important prognostic factor (Wald chi-square 153.6) after older age (Wald chi-square 241.2) in the multivariable bleeding model. Overall 1-year mortality was similar in women and men after adjusting for prognostically important baseline differences (hazard ratio HR 1.06, 95% CI 0.97 to 1.17). However, after adjustment for baseline confounders and bleeding, female gender was associated with a lower risk of 1-year death. Thus, adjusted 1-year mortality was similar in women compared to men without bleeding (HR 1.08, 95% CI 0.97 to 1.19) but lower in women compared to men with bleeding (HR 0.85, 95% CI 0.73 to 0.98, p for interaction of gender by bleeding = 0.0016). The highest adjusted 1-year mortality was observed in men with bleeding (HR 2.42, 95% CI 2.20 to 2.66) followed by women with bleeding (HR 2.05, 95% CI 1.80 to 2.33) and women without bleeding (HR 1.08, 95% CI 0.97 to 1.19, referent men without bleeding). In conclusion, in patients with fibrinolytic-treated STEMI, women had a higher incidence but lower mortality with bleeding than men. These data highlight the importance of understanding factors associated with gender-related differences in bleeding and represent an opportunity for improving outcomes of women and men with fibrinolytic-treated STEMI.
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The prognostic significance of postprocedure sustained ventricular tachycardia or ventricular fibrillation (VT/VF) in patients undergoing primary percutaneous coronary intervention (PPCI) for ...ST-segment elevation myocardial infarction (STEMI) has rarely been studied, although a previous study has suggested that its occurrence portends decreased survival. We examined outcomes from the prospective large-scale multicenter randomized HORIZONS-AMI trial to evaluate the incidence, clinical correlates, and outcomes of in-hospital sustained VT/VF after PPCI. Of 3,485 patients undergoing PPCI in whom VT/VF did not occur before or during the procedure, 181 patients (5.2%) developed VT/VF after PPCI. Most postprocedural VT/VF episodes (85%) occurred in the first 48 hours. Patients with postprocedural VT/VF were more likely men with Killip class >I on presentation but had a lower prevalence of hypertension and diabetes. Patients with postprocedural VT/VF were also less frequently taking β blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at admission. Mean door-to-balloon time was shorter and Thrombolysis In Myocardial Infarction grade 0 flow before PPCI was more common in patients with VT/VF, although Thrombolysis In Myocardial Infarction grade 3 flow rates after PPCI did not vary. There were no significant differences in adjusted 3-year rates of mortality (hazard ratio 0.73, 95% confidence interval 0.30 to 1.79) or composite major adverse clinical events (death, myocardial infarction, target vessel revascularization, or stroke; hazard ratio 0.71, 95% confidence interval 0.44 to 1.15) in patients with versus without postprocedural sustained VT/VF. In conclusion, sustained VT/VF after PPCI in the HORIZONS-AMI trial was not significantly associated with 3-year mortality or major adverse clinical events. Further studies are required to address the prognostic significance of VT/VF in patients with STEMI undergoing PPCI.
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Abstract Background Studies have shown higher bleeding and mortality rates among African Americans who receive fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) compared ...with whites; however, the relationship of bleeding risk to mortality has not been evaluated. Methods We studied data from 32,260 STEMI patients receiving fibrinolysis enrolled in the US in 5 clinical trials. Bleeding was defined according to criteria from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries study. Main outcome measure was adjusted 1-year mortality. Results Despite younger age (median: 57 years vs 61 years) and fewer comorbidities, moderate or severe bleeding occurred more frequently among African-Americans than whites (16.3% vs 14.1%; P = .0147, adjusted OR 1.36; 95% confidence interval CI, 1.14-1.62; P = .0006) as did 1-year mortality (11.5% vs 9.4%). African-American race and moderate or severe bleeding were independently related to 1-year mortality (χ2 9.02, P = .0003 and 148.58, P < .0001, respectively). Mortality was highest among African Americans with bleeding (hazard ratio HR 2.83; 95% CI, 2.08-3.86) followed by whites with bleeding (HR 1.99; 95% CI, 1.78-2.22) and African Americans without bleeding (HR 1.33; 95% CI, 1.02-1.73) (referent whites without bleeding). Conclusions In STEMI patients receiving fibrinolysis, moderate or severe bleeding and mortality were significantly higher in African Americans compared with whites. Bleeding was associated with similarly increased mortality risk in both groups.
Abstract Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in perioperative pain management of patients undergoing coronary artery bypass graft surgery. However, the ...association of periprocedural use of NSAIDs and clinical outcomes after coronary artery bypass graft is understudied. Methods We conducted a retrospective analysis using pooled data from 2 multicenter randomized controlled trials (PREVENT IV n = 3014 and MEND-CABG II n = 3023). Rates of death, death or myocardial infarction, and death, myocardial infarction, or stroke in the 30 days following coronary artery bypass graft surgery were compared in patients using or not using perioperative NSAIDs. Inverse probability of treatment weighting and Cox proportional hazards regression models were used to adjust for confounding. Results A total of 5887 patients were studied. Median age was 65 years, 78% were male, and 91% were White. NSAIDs were used in 2368 (40.2%) patients. The majority of patients (1822 30.9%) received NSAIDs after coronary artery bypass graft surgery; 289 (4.9%) used them prior to and after the surgery; and 257 (4.4) received NSAIDs prior to the surgery only. Adjusted 30-day outcomes were similar in patients receiving and not receiving NSAIDs (death: hazard ratio HR 1.18; 95% confidence interval CI, 0.48-2.92; death or myocardial infarction: HR 0.87; 95% CI, 0.42-1.79; death, myocardial infarction, or stroke: HR 0.87; 95% CI, 0.46-1.65). Conclusion In this pooled data analysis, perioperative NSAID use was common among patients undergoing coronary artery bypass graft surgery and was not associated with an increased short-term risk for major adverse clinical outcomes.
Clinical Significance of Post-Procedural TIMI Flow in Patients With Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention Rajendra H. Mehta, Fang-Shu Ou, Eric D. Peterson, Richard ...E. Shaw, William B. Hillegass, Jr, John S. Rumsfeld, Matthew T. Roe, on behalf of the American College of Cardiology–National Cardiovascular Database Registry Investigators We examined 4,731 patients with cardiogenic shock and ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) from the American College of Cardiology–National Cardiovascular Database CathPCI Registry to determine the association of post-procedural Thrombolysis In Myocardial Infarction (TIMI) flow grades 0 to 2 in infarct-related artery (IRA) with outcomes. We found that post-PCI TIMI flow grades 0 to 2 in the IRA occurred in 14.7% of patients. Mortality was higher with TIMI flow grades 0 to 2 versus TIMI flow grade 3 (63% vs. 27%). There was inverse relationship with TIMI flow in the IRA and adjusted mortality (TIMI flow grades 0/1 odds ratio OR: 5.47 95% confidence interval (CI): 4.13 to 7.24; TIMI flow grade 2 OR: 2.63 95% CI: 2.02 to 3.42 compared with TIMI flow grade 3).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Nadir hematocrit on cardiopulmonary bypass (CPB) is a known risk factor for worse outcomes after cardiac surgery. Whether women, because of lower nadir hematocrit on CPB, are more prone to ...worse outcomes than men after cardiac surgery remains unknown. Methods We evaluated 13,734 patients (31.3% women) undergoing cardiac surgery (6/1/2001 to 06/30/2011) to study the association of hematocrit on CPB and gender with postoperative acute kidney injury (AKI) stage 2-3 (increase in creatinine at least twice the baseline), and operative mortality. Results Women were older (68 ± 12 vs 65 ± 12 years, p < 0.001), with more comorbidities. Baseline (37.4% ± 4.4% vs 39.8% ± 4.6%, p < 0.001) and nadir (24.5% ± 3.5% vs 27.4% ± 3.6%, p < 0.001) hematocrit were lower, whereas the hematocrit drop on CPB (baseline and nadir) was greater in women (12.9% ± 4.35 vs 12.4% ± 4.2%, p < 0.001). Observed AKI stage 2-3 and mortality rates were significantly higher in women than in men (5.8% vs 4.9%, p = 0.025 and 4.3% vs 3.4%, p = 0.009, respectively). While nadir hematocrit was inversely related to AKI stage 2-3 and death in both genders, the subgroup of patients with severe hemodilution (nadir hematocrit ≤ 22%) demonstrated a nonsignificant higher rate of AKI stage 2-3 in men (9.2% vs 7.8%) and a significant higher mortality in men (11% vs 7.6%) compared with women. Conclusions Both men and women undergoing cardiac surgery on CPB were prone to the deleterious effects of hemodilution on renal function and death. Yet, despite greater hemodilution, women had a lower relative risk of AKI and death than men at lower nadir hematocrit values on CPB suggesting better tolerance to hemodilution in women.
Background Aspiration thrombectomy is used in primary percutaneous coronary interventions, but the importance of thrombus constituency has been scarcely investigated. The objective of this study was ...to evaluate thrombus constituency and its association with clinical, laboratory, and angiographic findings in patients with ST-segment elevation myocardial infarction. Methods From April 2010 to May 2011, 562 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary interventions were considered for inclusion, and information on thrombi characteristics was available for 113 patients. Thrombus material were obtained and classified as white or red based on its constituency. Samples were analyzed by 3 independent pathologists blinded to clinical characteristics. Results The mean age of patients was 58.6 ± 12.7 years, and 69% were men. White thrombi were present in 31% of cases, and red thrombi, in 69%. Patients with white thrombi had smaller vessels and lower ischemic times. All other clinical, angiographic, and laboratory characteristics did not differ. White thrombi were smaller and associated with fibrin infiltration, whereas red thrombi were associated with red blood cell infiltration. Thirty-day death rates were lower in patients with white thrombi than red (0% vs 10.1%, respectively; P = .05), as were 30-day major adverse cardiac event rates (4.2% vs 13.9%; P = .10). Total ischemic time was well correlated with fibrin infiltration ( R = −0.30; P < .01), red blood cell infiltration ( R = 0.27; P < .01), and thrombus volume ( R = 0.22; P = .02). Conclusions White thrombi were present in one-third of cases and were associated with lower ischemic times, higher fibrin infiltration, smaller thrombus volume, and lower mortality. These findings suggest that thrombus constituency may be a useful prognostic tool in this setting.
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