This study was conducted to identify preoperative predictors of postoperative atrial fibrillation (POAF) after isolated coronary artery bypass grafting (CABG) by using a Bayesian analysis that ...included information from prior studies.
We performed a prospective observational study from October 2008 to December 2013 of 1,481 patients who underwent isolated CABG with cardiopulmonary bypass and had no history of AF. Bayesian analysis was used to study the preoperative risks factors for POAF.
The POAF incidence was 21%. Multivariate analysis identified the following independent predictors of POAF after CABG: high CHA
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-VASc (Congestive heart failure, Hypertension blood pressure >140/90 mm Hg or treated hypertension on medication, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, vascular disease, Age 65 to 74 years, Sex category female sex) score (odds ratio OR, 1.23; 95% credible interval CI, 1.14 to 1.33 per 1-point increment, probability (Pr) OR > 1 = 1), severe obesity with a body mass index of 35 kg/m
or higher (OR, 1.28; 95% CI, 1.12 to 1.45; Pr OR > 1 = 1), preoperative β-blocker use (OR, 1.12; 95% CI, 1.06 to 1.20; Pr OR > 1 = 1), preoperative antiplatelet therapy (OR, 1.75; 95% CI, 1.14 to 2.79, Pr OR > 1 = 1), and renal insufficiency with a creatinine clearance of less than 60 mL/min (OR, 1.34; 95% CI, 1.03 to 1.74; Pr OR > 1 = 1).
This prospective Bayesian analysis identified five independent preoperative predictors of POAF after isolated CABG with cardiopulmonary bypass: CHA
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-VASc score, severe obesity, preoperative β-blocker use, preoperative antiplatelet therapy, and renal failure. The main interest in the CHA
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-VASc score as a predictor of POAF is that it is a simple and widely used bedside tool. Patients with these independent predictors of POAF may constitute a target population to test preventive strategies, such as non-antiarrhythmic and antiarrhythmic drugs.
Unfractionated heparin has been the standard anticoagulant used immediately after mechanical heart valve replacement (MHVR). The purpose of this study was to assess a postoperative anticoagulation ...protocol with low-molecular-weight heparin (LMWH) immediately after MHVR without the use of unfractionated heparin or anti-factor Xa monitoring.
We performed a prospective, single-center, observational study of 1,063 consecutive patients undergoing elective MHVR with postoperative LMWH anticoagulation treatment. The exclusion criteria were as follows: renal failure, intraaortic balloon counterpulsation, critical perioperative state, or a recent neurologic event. The postoperative anticoagulation protocol used subcutaneous enoxaparin as a bridging anticoagulant treatment beginning on the first postoperative day and continuing until vitamin K antagonist treatment was fully effective. Patients were followed for 6 weeks. The primary endpoints were the incidence of thromboembolic or major bleeding events.
Eleven (1%) thromboembolic events occurred. Ten of these events were transient or permanent strokes. Major bleeding events occurred in 44 patients (4.1%), 7 of which were observed before the enoxaparin treatment period. At the time of discharge, 570 patients (53.6%) were no longer receiving LMWH treatment due to achieving the target international normalized ratio. The mean length of hospital stay was 8.5 ± 2.9 days. There were no deaths during the 6-week follow-up period.
In our highly selected population, after MHVR, postoperative anticoagulation using LMWH is associated with a low rate of thromboembolic and major bleeding events. This large observational study demonstrates that the use of LMWH as an anticoagulant is effective and safe after MHVR.
Abstract Introduction Evidence regarding the behavior of fibrinogen levels and the relation between fibrinogen levels and postoperative bleeding is limited in cardiac surgery under cardiopulmonary ...bypass (CPB). To evaluate perioperative fibrinogen levels as a predictor of postoperative bleeding in patients undergoing cardiac surgery with CPB. Materials and Methods In this prospective, single-center, observational cohort study of 1956 patients following cardiac surgery with CPB, fibrinogen level was measured perioperatively. Excessive bleeding group was defined as patients with a 24-h chest tube output (CTO) exceeded the 90th percentile of distribution. Results The median 24-h CTO was 728.6 ± 431.1 ml. A total of 189 patients (9.7%) were identified as having excessive bleeding. At admission to the intensive care (Day 0), the fibrinogen levels were 2.5 ± 0.8 g/l and 2.1 ± 0.8 g/l in the control and excessive bleeding groups, respectively ( P < 0.0001 ). The fibrinogen level on Day 0 was significantly correlated with the 24-h CTO (rho = -0.237; P < 0.0001 ). Multivariate analysis demonstrated that the fibrinogen level at Day 0 was the best perioperative standard laboratory test to predict excessive bleeding (P = 0.0001; odds ratio, 0.5), whereas preoperative fibrinogen level was not a predictor. Using receiver operating characteristics curve analyses, the best Day 0 fibrinogen level cutoff to predict postoperative bleeding was 2.2 g/l. Conclusions In this large prospective study, the fibrinogen level upon admission to the intensive care unit after CPB predicted the risk of postoperative bleeding. Our data add to the concern regarding the fibrinogen level threshold that might require fibrinogen concentrate infusion to reduce postoperative blood loss.
Abstract Background Obesity is suggested to reduce postoperative bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) but perioperative hemostasis variations have not ...been studied. Therefore, we investigated the effects of severe obesity (body mass index BMI ≥ 35 kg/m2 ) on chest tube output (CTO) and hemostasis in patients undergoing cardiac surgery with CPB. Materials and Methods We prospectively investigated 2799 consecutive patients who underwent coronary and/or valve surgery using CPB between 2008 and 2012. 204 patients (7.3%) presented a severe obesity. Results In the severe obesity group, the 6-h and 24-h CTO were significantly reduced by -21.8% and -14.8% respectively (P < 0.0001) compared with the control group. A significant reduction of the mean number of red blood cell units transfused at 24 h was observed in the severe obesity groups (P = 0.01). On admission to the intensive care unit, a significant increase of platelet count (+ 9.2%; P < 0.0001), fibrinogen level (+ 12.2%; P < 0.0001) and prothrombin time (+ 4.1%; P < 0.01) and a significant decrease of the activated partial thromboplastin time (-4.2%; P < 0.01) were observed in the severe obesity group compared with the control group. In multivariate analysis, severe obesity was significantly associated to a decreased risk of excessive bleeding (24-h CTO > 90th percentile; Odds ratio: 0.37, 95% CI: 0.17 to 0.82). No significant differences were observed regarding postoperative thromboembolic events between the two groups. Conclusions Severe obesity is associated with a prothrombotic postoperative state that leads to a reduction of postoperative blood loss in patients undergoing cardiac surgery with CPB.
The PARTNER trial has shown that TAVI is not inferior to surgical aortic valve replacement (AVR) in high-risk aortic stenosis. However, real life registry comparing TAVI and surgery are lacking.
...monocentric registry of high-risk patients (lEUROSCORE1 ≥15%) undergoing TAVI (114 patients) or AVR (81 patients) between 2009 and 2013 in our institution.
Mean age was 84,4 and 83,6 yo (p=NS). TAVI patients had higher EUROSCORE1 (31 vs 24.5%, p<0,001), lower LVEF (48,4 vs 57%, p<0,0001) and lower mean aortic gradient (46 vs 53mmHg, p=0,0001). Mortality in-hospital was not statistically different between TAVI and AVR; 9,6 vs 17,3% respectively (p=0,12). TAVI patients presented more vascular complications (11,4 vs 0%, p= 0,001), needed more Pace-Maker (24,6 vs 4,9%, p<0,0001) but presented less in-hospital infections (11 vs 19%, p=0,008), less new atrial fibrillation (20 vs 41%, p=0,002), and needed less transfusions (25,4 vs 80,2%, p<0,0001).
The present registry results confirm that TAVI is a real alternative to surgery in patients with at high surgical risk. Longer follow up is required to confirm these results.Abstract 0258 – Table.AVRTAVIpn81114Age83.684.40.21Euroscore1 (%)24.531<0.0001FEV (%)57.148.5<0.0001DTVG (mm)51540.086Mean Gradient (mmHg)53460.008Creatinin pre (microM/L)1111380.003Hemoglobin pre (g/100)12.611.6<0.0001Death (%)17.39.60.12Vascular complication (%)011.40.001Infection (%)19110.008Dialysis (%)13.611.40.65AFIB post (%)41200.002Pericardial effusion (%)2.58.80.13Stroke (%)4.91.80.23Pace Maker (%)4.924.6<0.0001Transfusions (%)8025<0.0001
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