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1.
Trials ; 25(1): 324, 2024 May 16.
Article in English | MEDLINE | ID: mdl-38755709

ABSTRACT

BACKGROUND: The optimal antithrombotic strategy early after aortic valve replacement surgery with a biological valve remains controversial due to lack of high-quality evidence. Either oral anticoagulants or acetylsalicylic acid should be considered for the first 3 months. Hypo-attenuated leaflet thickening on cardiac computed tomography has been associated with latent bioprosthetic valve thrombosis and may be prevented with anticoagulation. We hypothesize that anticoagulation with apixaban is superior to single antiplatelet therapy with acetylsalicylic acid in reducing hypo-attenuated leaflet thickening of bioprosthetic aortic valve prostheses. METHODS: In this prospective, open-label, randomized trial, patients undergoing isolated aortic valve replacement surgery with rapid deployment bioprosthetic valves will be randomized. The treatment group will receive 5 mg of apixaban twice a day for the first 3 months and 100 mg of acetylsalicylic acid thereafter. The control group will be administered 100 mg of acetylsalicylic acid once a day, indefinitely. After the 3-month treatment period, a contrast-enhanced electrocardiogram-gated cardiac computed tomography will be performed to identify hypo-attenuated leaflet thickening of the bioprosthetic valve. The primary objective of the study is to assess the impact of apixaban on the prevention of hypo-attenuated leaflet thickening at 3 months. The secondary and exploratory endpoints will be clinical outcomes and safety profiles of the two strategies. DISCUSSION: Antithrombotic therapy after aortic valve replacement is used to prevent valve thrombosis and systemic thromboembolism. Latent bioprosthetic valve thrombosis is a precursor of clinically significant prosthetic valve dysfunction or thromboembolic events. The hallmark feature of latent bioprosthetic valve thrombosis is hypo-attenuated leaflet thickening on cardiac computed tomography. Subclinical leaflet thrombosis occurs frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. There is no evidence on the effect of direct oral anticoagulants on the incidence of hypo-attenuated leaflet thickening after surgical aortic valve replacement with rapid deployment bioprostheses. TRIAL REGISTRATION: ClinicalTrials.gov NCT06184113. Registered on December 28, 2023.


Subject(s)
Aortic Valve , Aspirin , Factor Xa Inhibitors , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Adult , Aged , Female , Humans , Male , Middle Aged , Aortic Valve/surgery , Aortic Valve/diagnostic imaging , Aspirin/administration & dosage , Aspirin/therapeutic use , Aspirin/adverse effects , Bioprosthesis , Factor Xa Inhibitors/administration & dosage , Factor Xa Inhibitors/adverse effects , Factor Xa Inhibitors/therapeutic use , Fibrinolytic Agents/administration & dosage , Fibrinolytic Agents/adverse effects , Heart Valve Prosthesis/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/methods , Platelet Aggregation Inhibitors/administration & dosage , Platelet Aggregation Inhibitors/therapeutic use , Platelet Aggregation Inhibitors/adverse effects , Prospective Studies , Pyrazoles/therapeutic use , Pyrazoles/administration & dosage , Pyrazoles/adverse effects , Pyridones/therapeutic use , Pyridones/administration & dosage , Pyridones/adverse effects , Randomized Controlled Trials as Topic , Thrombosis/prevention & control , Thrombosis/etiology , Time Factors , Treatment Outcome
2.
Heart Surg Forum ; 26(1): E038-E039, 2023 Jan 31.
Article in English | MEDLINE | ID: mdl-36856506

ABSTRACT

A 44-year-old female patient with chemotherapy-induced cardiomyopathy presented with acute cardiogenic shock requiring ECMO support. Multiple failed weaning trials from temporary mechanical circulatory assistance prompted a transition to staged durable biventricular support. Her course was complicated with recurrent RVAD stoppages. The initial event was treated with pump exchange, while for the subsequent RVAD standstill, we employed a device wash-out and reimplantation strategy. A brief period of circulatory arrest was employed to explore the right-sided cardiac chambers using a single-use bronchoscope.


Subject(s)
Dextrocardia , Heart Arrest , Heart-Assist Devices , Humans , Female , Adult , Shock, Cardiogenic
3.
ESC Heart Fail ; 10(3): 2094-2098, 2023 06.
Article in English | MEDLINE | ID: mdl-36896803

ABSTRACT

A 47-year old male with ischaemic cardiomyopathy was referred to us for durable left ventricular assist device placement. He was found to have prohibitively elevated pulmonary vascular resistance for heart transplantation. He underwent HeartMate 3 left ventricular assist device implantation, with additional temporary right ventricular assist device (RVAD) placement. Following a 2-week period of unweanable temporary right ventricular support, the patient was switched to durable biventricular support with two Heartmate 3 pumps. The patient was placed on a transplant waiting list but was not offered a heart for over 4 years. While on Heartmate 3 biventricular support (BiVAD), he returned to full activity and enjoyed an excellent quality of life. He underwent laparoscopic cholecystectomy 7 months after the BIVAD implant. After 52 months of uneventful BiVAD support, he presented with a combination of adverse events that occurred over a short period. These included subarachnoidal haemorrhage and a new motor deficit, followed by RVAD infection and RVAD low-flow alarms. After over 4 years of unimpeded RVAD flows, new imaging revealed an outflow graft twist with subsequent flow reduction. The patient underwent heart transplantation after a total of 1655 days of Heartmate 3 BiVAD support and continues to do well on latest follow-up.


Subject(s)
Heart Failure , Heart Transplantation , Heart-Assist Devices , Male , Humans , Middle Aged , Heart Failure/surgery , Heart Failure/etiology , Quality of Life , Heart-Assist Devices/adverse effects , Postoperative Complications/etiology
4.
Croat Med J ; 63(5): 423-430, 2022 Oct 31.
Article in English | MEDLINE | ID: mdl-36325666

ABSTRACT

AIM: To evaluate the impact of minimally invasive aortic valve replacement (mini-AVR) on clinical outcomes in comparison with the gold standard. METHODS: We retrospectively reviewed the records of all patients who underwent isolated AVR at the University Hospital Center Zagreb from 2010 to 2020. Patients undergoing mini-AVR were compared with patients undergoing conventional AVR (fs-AVR). The primary outcome measure was blood product consumption. Propensity score matching was used to create a balanced covariate distribution across treatment groups. Additionally, we compared the contemporary outcomes with a historical control. RESULTS: The final sample consisted of 1088 patients. In the unmatched cohorts, mini-AVR patients were younger (65±12 vs 68±10 years, P<0.001) and had lower risk profiles (EuroSCORE2 2.8±2.0 vs 3.5±3.1, P=0.003). After matching, mini-AVR patients required less blood transfusion than fs-AVR patients (270 [0-790] vs 510 [0-970] mL, P=0.029). The incidences of stroke, dialysis, new AV block, and mortality were comparable. Cross-clamp times were longer in the mini-AVR group (71 [60-87] vs 66 [53-83] minutes, P=0.013). Outcomes were improved in the contemporary mini-AVR era compared with our early mini-AVR experience across multiple metrics. Blood product consumption was reduced in the latter tercile of experience (0 [0-520] vs 500 [0-1018] mL, P<0.001), and the operation was performed more expeditiously (cross-clamp times: 63 [54,80] vs 74 [62,88] minutes, P<0.001) in comparison with earlier periods. CONCLUSIONS: We showed that mini-AVR was associated with less blood product requirement than conventional surgery. Our data supports wider adoption of minimally invasive techniques in dedicated centers of excellence.


Subject(s)
Aortic Valve , Heart Valve Prosthesis Implantation , Humans , Aortic Valve/surgery , Propensity Score , Heart Valve Prosthesis Implantation/methods , Retrospective Studies , Sternotomy/methods , Treatment Outcome , Minimally Invasive Surgical Procedures/methods
5.
Braz J Cardiovasc Surg ; 37(Spec 1): 57-65, 2022 09 02.
Article in English | MEDLINE | ID: mdl-36054003

ABSTRACT

The saphenous vein is the most used conduit for coronary artery bypass surgery. However, the patency rate of this graft is inferior to the internal thoracic artery patency rate, which is the gold standard. Using the conventional technique, the saphenous vein is harvested via a large open incision and excised in such a way that causes both vascular damage and wound healing complications. Consequently, vein graft patency and surgical site infection may be compromised. Graft patency is markedly improved when the saphenous vein is harvested atraumatically with minimal damage and with surrounding cushion of perivascular fat intact. However, despite the improved graft performance, wound healing complications and infection remain a problem. Although wound healing complication is reduced when using endoscopic vein harvesting, there may be a negative impact on graft performance. This is due to vascular damage associated with application of forces to the vein that are usually avoided in open vein harvesting, including traction, adventitial stripping, and venous compression. There is evidence to suggest that improved patency of endoscopically harvested saphenous veins is associated with the surgeon's experience of the technique. Recently, endoscopic methods of harvesting have been described where the saphenous vein is removed intact and with minimal vascular damage caused. In addition, wound healing complications, infection, and scarring are reduced. While the effect of these techniques on vein graft patency have yet to be reported, the ability to obtain a superior graft with reduced wound complications will be of great benefit to patients undergoing coronary revascularization procedures.


Subject(s)
Mammary Arteries , Saphenous Vein , Coronary Artery Bypass/methods , Humans , Mammary Arteries/transplantation , Saphenous Vein/transplantation , Tissue and Organ Harvesting , Vascular Patency
8.
Rev. bras. cir. cardiovasc ; 37(spe1): 57-65, 2022. tab, graf
Article in English | LILACS-Express | LILACS | ID: biblio-1407346

ABSTRACT

ABSTRACT The saphenous vein is the most used conduit for coronary artery bypass surgery. However, the patency rate of this graft is inferior to the internal thoracic artery patency rate, which is the gold standard. Using the conventional technique, the saphenous vein is harvested via a large open incision and excised in such a way that causes both vascular damage and wound healing complications. Consequently, vein graft patency and surgical site infection may be compromised. Graft patency is markedly improved when the saphenous vein is harvested atraumatically with minimal damage and with surrounding cushion of perivascular fat intact. However, despite the improved graft performance, wound healing complications and infection remain a problem. Although wound healing complication is reduced when using endoscopic vein harvesting, there may be a negative impact on graft performance. This is due to vascular damage associated with application of forces to the vein that are usually avoided in open vein harvesting, including traction, adventitial stripping, and venous compression. There is evidence to suggest that improved patency of endoscopically harvested saphenous veins is associated with the surgeon's experience of the technique. Recently, endoscopic methods of harvesting have been described where the saphenous vein is removed intact and with minimal vascular damage caused. In addition, wound healing complications, infection, and scarring are reduced. While the effect of these techniques on vein graft patency have yet to be reported, the ability to obtain a superior graft with reduced wound complications will be of great benefit to patients undergoing coronary revascularization procedures.

12.
Braz J Cardiovasc Surg ; 35(1): 91-99, 2020 02 01.
Article in English | MEDLINE | ID: mdl-32270965

ABSTRACT

The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.


Subject(s)
Mammary Arteries , Saphenous Vein , Coronary Artery Bypass , Humans , Treatment Outcome , Vascular Patency
13.
Rev. bras. cir. cardiovasc ; 35(1): 91-99, Jan.-Feb. 2020. tab, graf
Article in English | LILACS | ID: biblio-1092466

ABSTRACT

Abstract The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.


Subject(s)
Humans , Saphenous Vein , Mammary Arteries , Vascular Patency , Coronary Artery Bypass , Treatment Outcome
14.
Croat Med J ; 60(3): 255-264, 2019 06 13.
Article in English | MEDLINE | ID: mdl-31187954

ABSTRACT

AIM: To investigate the prevalence of burnout syndrome among physicians of all specialties, including residents and non-specialists, on a national level in Croatia. METHODS: This cross-sectional study, conducted in October 2017, used anonymous online survey based on the Maslach Burnout Inventory Human Services Survey. The Croatian version of the inventory was assessed for acceptability, factorial validity, and reliability. Key dimensions of burnout - emotional exhaustion, depersonalization, and lack of personal accomplishment were assessed. Respondents scoring high for emotional exhaustion or depersonalization were defined as burned-out. RESULTS: The response rate was 18% (2557/14 427). Respondents' median age was 41 years (range 25-80), and 68% (1737/2557) were women. Good sampling adequacy and scale reliability were confirmed. Factorial validity suggested the presence of three overall factors, and no items were eliminated. Sixty-three percent of physicians were burned-out. High score on emotional exhaustion, depersonalization, and reduced personal accomplishment were found in 58%, 29%, and 52% of respondents, respectively. As many as 16% of the respondents simultaneously experienced high levels of all three burnout dimensions. Multivariate logistic regression analysis revealed that residents and physicians in tertiary or primary care were at an increased risk of burnout, while physicians working in institutes were at a decreased risk. CONCLUSION: Active national measures are needed to reduce the high prevalence of burnout among Croatian physicians.


Subject(s)
Burnout, Professional/epidemiology , Physicians/psychology , Physicians/statistics & numerical data , Primary Health Care/statistics & numerical data , Adult , Aged , Aged, 80 and over , Croatia/epidemiology , Cross-Sectional Studies , Depersonalization , Emotions , Family Practice/statistics & numerical data , Female , Humans , Male , Middle Aged , Personal Satisfaction , Prevalence , Surveys and Questionnaires , Tertiary Healthcare/statistics & numerical data
15.
Eur J Cardiothorac Surg ; 55(2): 358-365, 2019 02 01.
Article in English | MEDLINE | ID: mdl-30084901

ABSTRACT

OBJECTIVES: The aim of this study was to analyse outcomes over 2 decades using cryopreserved vascular allografts to treat vascular infection. METHODS: We conducted a retrospective study of patients identified from our institutional database who were treated for primary or secondary vascular infection using implanted allografts. RESULTS: Between October 1992 and May 2014, 54 patients underwent surgery for vascular infection out of 118 patients implanted with cryopreserved vascular allografts. The 52 patients for whom we had full information form the basis of the study with a 96% follow-up. The average age was 64 ± 11 years; 87% were men; 65% had previous vascular surgery; 19% had emergency operations. A total of 75% of the patients had aortoiliofemoral infections. Five patients underwent surgery with cardiopulmonary bypass. Fifty percent required more than 1 allograft and 15% had concomitant procedures. Seventy-three percent (38/52) of specimen cultures yielded positive results with polymicrobial flora in 29%. Surgical specimens most frequently grew coagulase-negative staphylococci. The early postoperative reoperation rate was 15% for allograft-related complications. There were 20 (38%) early deaths, including deaths of acute myocardial infarction, anastomosis rupture and persistent sepsis and shock. Uncontrolled infection leading to septic shock and multiple organ failure was the cause of death in 50% of the cases. The mean duration of freedom from allograft reintervention was 12.2 years. The mean duration of freedom from allograft occlusion or limb loss was 12.1 years [95% confidence interval (CI) 9.9-14.4]. Of the 32 surviving patients, we had patency information for 66% obtained by angiography or computed tomography. The mean survival for the cohort was 5.9 years (95% CI 3.9-7.8). Mean freedom from cardiovascular infection-related death was 9.3 years (95% CI 7.2-11.4). CONCLUSIONS: Allografts can be indicated for treatment of primary/secondary infection and have remarkable results in multimorbid patients. Patients with vascular infection have a high-risk profile, around 40% mortality during the first 6 months, with reduction in overall mortality thereafter. We believe that allografts may play a role in the surgical treatment of vascular infection.


Subject(s)
Allografts/transplantation , Blood Vessel Prosthesis , Cryopreservation , Vascular Diseases/surgery , Vascular Grafting , Aged , Arteries/surgery , Arteries/transplantation , Blood Vessel Prosthesis/adverse effects , Blood Vessel Prosthesis/statistics & numerical data , Female , Humans , Male , Middle Aged , Prosthesis-Related Infections/surgery , Retrospective Studies , Survival Analysis , Vascular Grafting/adverse effects , Vascular Grafting/methods , Vascular Grafting/mortality , Vascular Grafting/statistics & numerical data
16.
J Thorac Cardiovasc Surg ; 157(4): 1466-1476.e3, 2019 04.
Article in English | MEDLINE | ID: mdl-30448166

ABSTRACT

BACKGROUND: Neurological complications after coronary artery bypass grafting (CABG) reduce quality of life, increase mortality, and inflate resource utilization. The risk of postoperative neurological complications parallels the increasing risk burden of the contemporary patient population. We evaluated the efficacy of remote ischemic preconditioning (RIPC) on inducing neuroprotection. METHODS: Seventy patients undergoing first-time CABG were randomly assigned to RIPC or a sham procedure. Structural brain magnetic resonance imaging (MRI) was complemented with functional connectivity MRI to gain a whole-brain global connectivity analysis. Paired neurocognitive and MRI data were acquired pre- and postoperatively. The primary end point was a composite of new ischemic brain lesions and neurocognitive impairment. Secondary end points included brain connectivity profiles, pooled ischemic volumes, and individual components of the primary outcome. The Shapiro-Wilk test was used to determine whether a data set followed a normal distribution. The Fisher exact test was used to calculate the measures of association for categorical variables, whereas continuous data were tested with either the Mann-Whitney U test or the Student t test. RESULTS: There was no between-group difference in the incidence of the primary end point (9 [27%] in the RIPC group vs 8 [24%] in the control group, odds ratio, 1.17 [95% confidence interval, 0.34-4.06]; P = 1.0). Although RIPC did not reduce the incidence of brain ischemia (8/33 [24%] vs 7/33 [21%]; P = 1.0), the pooled ischemic volume was lower in the RIPC group (157 [interquartile range, 125-231] vs 777 [interquartile range, 564-965] mm3; P = .004). Postoperative neurocognition was marginally superior in the RIPC group as evidenced by a lower absolute number of abnormal neurocognitive tests in the RIPC group (7/99 [7%] vs 16/99 [16%]; odds ratio, 0.40 [95% confidence interval, 0.14-1.09]; P = .074). Robust reductions of functional connectivity profiles for the associative thalamus were documented in both groups, irrespective of RIPC (RIPC group, t = 3.31; P < .01; and the control group, t = 3.52; P < .01). CONCLUSIONS: Silent brain ischemia occurs frequently after CABG. RIPC did not reduce the incidence of the primary outcome. However, RIPC significantly reduced the pooled volume of ischemic brain lesions. Surgery adversely affected global brain connectivity, with RIPC conferring no demonstrable protection. The association of RIPC with superior neurocognitive test scores failed to cross the threshold for significance.


Subject(s)
Brain Ischemia/prevention & control , Coronary Artery Bypass , Coronary Artery Disease/surgery , Ischemic Preconditioning/methods , Therapeutic Occlusion , Upper Extremity/blood supply , Aged , Brain Ischemia/diagnostic imaging , Brain Ischemia/etiology , Brain Ischemia/psychology , Coronary Artery Bypass/adverse effects , Coronary Artery Disease/diagnosis , Croatia , Female , Humans , Ischemic Preconditioning/adverse effects , Magnetic Resonance Imaging , Male , Middle Aged , Neuropsychological Tests , Regional Blood Flow , Risk Factors , Therapeutic Occlusion/adverse effects , Time Factors , Treatment Outcome
19.
Ann Thorac Surg ; 104(2): 704-711, 2017 Aug.
Article in English | MEDLINE | ID: mdl-28483150

ABSTRACT

Continuous-flow left ventricular assist devices (cf-LVAD) play an important role in the management of patients with advanced heart failure. De novo aortic regurgitation after cf-LVAD implantation may adversely impact device performance. We performed a systematic search of PubMed, SCOPUS, and Cochrane Library for articles reporting on the incidence and predictors of de novo aortic regurgitation among cf-LVAD recipients. Eight studies totaling 548 patients were identified in the meta-analysis. The pooled incidence of de novo AR across the analyzed studies was 37%. Factors influencing its development and progression are older age, persistent aortic valve closure, being female, and duration of cf-LVAD support.


Subject(s)
Aortic Valve Insufficiency/etiology , Heart Failure/surgery , Heart-Assist Devices/adverse effects , Postoperative Complications , Ventricular Function, Left/physiology , Disease Progression , Heart Failure/physiopathology , Humans
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