Synergistic Effect of Transmyocardial Revascularization and Platelet-Rich Plasma on Improving Cardiac Function After Coronary Artery Bypass Grafting.

Background Coronary artery disease (CAD) is a global health burden, contributing to mortality and morbidity. A proportion of patients with CAD suffer from diffuse CAD, where conventional revascularization techniques such as percutaneous coronary intervention and coronary artery bypass grafting (CABG) may be insufficient to adequately restore myocardial perfusion. Transmyocardial revascularization (TMR) uses a laser to create microscopic channels in the myocardium, inducing inflammation, angiogenesis, and neovascularization to improve perfusion to ischemic regions. Platelet-rich plasma (PRP) is an autologous concentrate of platelets that contains a myriad of growth factors and bioactive proteins, which have been shown to promote tissue regeneration and wound healing. The combination of TMR and PRP therapies has been proposed to synergistically enhance myocardial revascularization and functional recovery in patients with advanced CAD undergoing surgical revascularization. Methods This study evaluated the efficacy of combining TMR and PRP with CABG in improving cardiac function in diffuse CAD patients. Fifty-two patients were randomized to CABG alone (n = 16), CABG+TMR (n = 17), CABG+PRP (n = 10), and CABG+TMR+PRP (n = 9). TMR was performed using a holmium:YAG laser to create 10 channels in the inferolateral left ventricular wall. PRP was prepared from autologous whole blood and injected into the myocardium adjacent to the TMR channels. Cardiac function was assessed using speckle-tracking echocardiography preoperatively, postoperatively, and at one-year follow-up. Adverse events, including post-operative atrial fibrillation, acute kidney injury, and readmissions, were also recorded. Statistical analyses were performed to compare outcomes between the treatment groups. Results The CABG+TMR+PRP group showed significantly improved global longitudinal strain (GLS) at one year compared to CABG alone (mean GLS -15.96 vs -12.09, p = 0.02). Post-operative left ventricular ejection fraction trended higher in the TMR+PRP group (57.78%) vs other groups, but not significantly. Post-operative atrial fibrillation was higher in the TMR+PRP group (67% vs 25%, p = 0.04), potentially reflecting increased inflammation. No significant differences were observed in other adverse events. Conclusions The results of this study suggest a synergistic benefit of combining TMR and PRP therapies as an adjunct to CABG in patients with diffuse CAD. The significant improvement in GLS at one year in the TMR+PRP group compared to CABG alone indicates enhanced myocardial remodeling and functional recovery, which may translate to improved long-term outcomes. The higher incidence of postoperative atrial fibrillation in the TMR+PRP group warrants further investigation but may reflect the heightened inflammatory response necessary for angiogenesis and tissue regeneration. Prospective, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings and optimize treatment protocols. Nonetheless, concomitant TMR+PRP therapy represents a promising approach to augmenting myocardial revascularization and recovery in patients with advanced CAD undergoing surgical revascularization.

Prophylactic Left Atrial Appendage Ligation During Coronary Artery Bypass Graft Surgery Allows Safe Avoidance of Anticoagulation Regardless of Postoperative Atrial Fibrillation.

Background New-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia following cardiac surgery. POAF increases the risk of thromboembolism and stroke, as well as morbidity and mortality more generally. Despite evidence from the landmark PROTECT-AF and PREVAIL trials, left atrial appendage ligation (LAAL) is not routinely performed for thromboembolism prophylaxis in POAF, and anticoagulation remains the standard of care along with dual antiplatelet therapy. This study evaluated the efficacy of concomitant LAAL in eliminating the need for postoperative anticoagulation, regardless of POAF development, in patients undergoing coronary artery bypass grafting (CABG). Methods Between 2019 and 2021, 130 patients were selected to undergo concomitant LAAL while undergoing CABG surgery. Patients were then monitored for the incidence of new-onset POAF, and anticoagulation was strictly avoided for this indication. Demographic and outcome data were collected, with endpoints including transient ischemic attack (TIA) or stroke, death, and readmission within one year, as well as the length of hospital and intensive care unit (ICU) admissions. Results POAF occurred in 37 patients (28.5%), consistent with previous reports. However, none of the POAF patients experienced TIA or stroke during the one-year follow-up period, compared to 2 (2.15%) in the non-POAF group, a typical rate of postoperative stroke in such a patient population. No significant differences were observed between POAF and non-POAF cohorts in one-year stroke, all-cause mortality, readmission rates, or total hospital stay. Interestingly, the POAF cohort had a significantly longer mean ICU stay (4.24 vs 3.37 days, p = 0.0219), possibly due to the time required for arrhythmia control before discharge. The study population had a high mean CHA2DS2-VASc score (2.81), indicating an increased risk of thromboembolism, and a high mean HAS-BLED score, suggesting an elevated bleeding risk with anticoagulation. Conclusions LAAL appears to be an effective adjunct to CABG for thromboembolism prophylaxis in POAF. Formal anticoagulation was avoided in this study, with no significant differences in adverse events between POAF and non-POAF groups, suggesting that LAAL may be a suitable alternative to anticoagulation, especially in high-risk patients (e.g., those with elevated CHA2DS2-VASc or HAS-BLED scores). The safety and efficacy of this approach should be corroborated by larger randomized studies, such as the ongoing LeAAPS trial. LAAL during CABG may help reduce the risk of bleeding complications associated with anticoagulation while maintaining protection against thromboembolic events in patients who develop POAF.

Leveling Up: A Review of Machine Learning Models in the Cardiac ICU.

Machine learning has emerged as a significant tool to augment the medical decision-making process. Studies have steadily accrued detailing algorithms and models designed using machine learning to predict and anticipate pathologic states. The cardiac intensive care unit is an area where anticipation is crucial in the division between life and death. In this paper, we aim to review important studies describing the utility of machine learning algorithms to describe the future of artificial intelligence in the cardiac intensive care unit, especially in regards to the prediction of successful ventilatory weaning, acute respiratory distress syndrome, arrhythmia, and acute kidney injury.

Human Placental Allograft Membranes: Promising Role in Cardiac Surgery and Repair.

Despite the immense investment in research devoted to cardiovascular diseases, mechanisms of progression and potential treatments, it remains one of the leading causes of death in the world. Cellular based strategies have been explored for decades, having mixed results, while more recently inflammation and its role in healing, regeneration and disease progression has taken center stage. Placental membranes are immune privileged tissues whose native function is acting as a protective barrier during fetal development, a state which fosters regeneration and healing. Their unique properties stem from a complex composition of extracellular matrix, growth factors and cytokines involved in cellular growth, survival, and inflammation modulation. Placental allograft membranes have been used successfully in complex wound applications but their potential in cardiac wounds has only begun to be explored. Although limited, pre-clinical studies demonstrated benefits when using placental membranes compared to other standard of care options for pericardial repair or infarct wound covering, facilitating cardiomyogenesis of stem cell populations in vitro and supporting functional performance in vivo. Early clinical evidence also suggested use of placental allograft membranes as a cardiac wound covering with the potential to mitigate the predominantly inflammatory environment such as pericarditis and prevention of new onset post-operative atrial fibrillation. Together, these studies demonstrate the promising translational potential of placental allograft membranes as post-surgical cardiac wound coverings. However, the small number of publications on this topic highlights the need for further studies to better understand how to support the safe and efficient use of placenta allograft membranes in cardiac surgery.