Clopidogrel use after myocardial revascularization: prevalence, predictors, and one-year survival rate

Abstract Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. Objective: Identify predictors of clopidogrel following CABG. Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.

Factors Associated with Intubation Time and ICU Stay After CABG

ABSTRACT OBJECTIVE: The aim of this study was to identify factors associated with intubation time and intensive care unit stay after coronary artery bypass grafting with cardiopulmonary bypass. METHODS: This was a retrospective study, whose data collection was performed in the hospital charts of 160 patients over 18 years, who underwent surgery from September 2009 to July of 2013 in a hospital in the state of Espirito Santo, Brazil. RESULTS: The mean age of the subjects was 61.44±8.93 years old and 68.8% were male. Subjects had a mean of 5.17±8.42 days of intensive care unit stay and mean intubation time of 10.99±8.41 hours. We observed statistically significant positive correlation between the following variables: patients' age and intubation time; patients' age and intensive care unit stay; intubation time and intensive care unit stay. CONCLUSION: In conclusion, the study showed that older patients had longer intubation time and increased intensive care unit stay. Furthermore, patients with longer intubation time had increased intensive care unit stay.

Diclofenac plasma protein binding: PK-PD modelling in cardiac patients submitted to cardiopulmonary bypass

Twenty-four surgical patients of both sexes without cardiac, hepatic, renal or endocrine dysfunctions were divided into two groups: 10 cardiac surgical patients submitted to myocardial revascularization and cardiopulmonary bypass (CPB), 3 females and 7 males aged 65 ñ 11 years, 74 ñ 16 kg body weight, 166 ñ 9 cm height and 1.80 ñ 0.2l m2 body surface area (BSA), and control, 14 surgical patients not submitted to CPB, 11 female and 3 males aged 41 ñ 14 years, 66 ñ 14 kg body weight, 159 ñ 9 cm height and 1.65 ñ 0.16 m2 BSA (mean ñ SD). Sodium diclofenac (1 mg/kg, im Voltaren 75( twice a day) was administered to patients in the Recovery Unit 48 h after surgery. Venous blood samples were collected during a period of 0-12 h and analgesia was measured by the visual analogue scale(VAS) during the same period. Plasma diclofenac levels were measured by high performance liquid chromatography. A two-compartment open model was applied to obtain the plasma decay curve and to estimate kinetic parameters. Plasma diclofenac protein binding decreased whereas free plasma diclofenac levels were increased five-fold in CPB patients. Data obtained for analgesia reported as the maximum effect (EMA were: 25 per cent VAS (CPB) vs 1O per cent VAS (control), P<0.05, median measured by the visual analogue scale where lOO per cent is equivalent to the highest level of pain. To correlate the effect versus plasma diclofen levels, the EMAX sigmoid model was applied. A prolongation of the mean residence time for maximum effect (MRTEMAX) was observed without any change in lag-time in CPB in spite of the reduced analgesia reported for these patients, during the time-dose interval. In conclusion, the extent of plasma diclofenac protein binding was influenced by CPB with clinicall relevant kinetic-dynamic consequences.

Válvula mitral en "paracaídas": informe de un caso / Parachute mitral valve: Clinic case

Se informa de un lactante que después de haber tenido un periodo neonatal normal presentó una pobre ganancia de peso, fatiga al ser alimentado, infecciones de repetición. A la radiografía del tórax mostró cardiomegalia, con flujo pulmonar aumentado; y en el ecocardiograma, dilatación de la aurícula izquierda, con la válvula mitral con pendiente EF disminuida (12 m/seg), con un sólo músculo papilar y flujo diastólico transmitral turbulento, con área valvular estenótica (0.7 cm²). Con estos datos se hizo el diagnóstico de estenosis mitral por válvula mitral en "paracaídas". Fue llevado a cirugía a los 11 meses de edad y, ante la imposibilidad de hacerle la plastía, se le colocó una prótesis mitral mecánica. La evolución ha sido satisfactoria, con tratamiento médico a base de coumadin, dipiridamol y furosemida. Se resaltan las ventajas de la valoración no invasiva y el éxito de la cirugía