Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS: Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS: P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS: Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.

Heart Rate and Neurological Outcomes in Patients Undergoing Targeted Temperature Management.

INTRODUCTION: There is a paucity of data evaluating the impact of heart rate (HR) during Targeted Temperature Management (TTM) and neurologic outcomes. Current resuscitation guidelines do not specify a HR goal during TTM. We sought to determine the relationship between HR and neurologic outcomes in a single-center registry dataset. METHODS: We retrospectively studied 432 consecutive patients who completed TTM (33°C) after cardiac arrest from 2008 to 2017. We evaluated the relationship between neurologic outcomes and HR during TTM. Pittsburgh Cerebral Performance Categories (CPC) at discharge were used to determine neurological recovery. Statistical analysis included chi square, Student's t-test and Mann-Whitney U. A logistic regression model was created to evaluate the strength of contribution of selected variables on the outcome of interest. RESULTS: Approximately 94,000 HR data points from 432 patients were retrospectively analyzed; the mean HR was 82.17 bpm over the duration of TTM. Favorable neurological outcomes were seen in 160 (37%) patients. The mean HR in the patients with a favorable outcome was lower than the mean HR of those with an unfavorable outcome (79.98 bpm vs 85.67 bpm p < 0.001). Patients with an average HR of 60-91 bpm were 2.4 times more likely to have a favorable neurological outcome compared to than HR's < 60 or > 91 (odds ratio [OR] = 2.36, 95% confidence interval [CI] 1.61-3.46, p < 0.001). Specifically, mean HR's in the 73-82 bpm range had the greatest rate of favorable outcomes (OR 3.56, 95% CI 1.95-6.50), p < 0.001. Administration of epinephrine, a history of diabetes mellitus and hypertension all were associated with worse neurological outcomes independent of HR. CONCLUSION: During TTM, mean HRs between 60-91 showed a positive association with favorable outcomes. It is unclear whether a specific HR should be targeted during TTM or if heart rates between 60-91 bpm might be a sign of less neurological damage.

An Observation of Racial and Gender Disparities in Congestive Heart Failure Admissions Using the National Inpatient Sample.

Background Congestive heart failure (CHF) is a frequent cause of inpatient admissions in the United States. The purpose of this study was to analyze the racial and gender disparities that occur in CHF admissions and determine the impact of these disparities on medical expenditure. Methods We analyzed the National Inpatient Sample (NIS) database from 2009 to 2014 for patients with a primary discharge diagnosis of CHF, and further stratified the cohort on the basis of race and sex. Multivariate analysis was performed to identify the association between CHF and total charges along with other variables such as mortality, length of stay (LOS), and number of procedures. Results There were a total of 5,491,050 admissions with a primary diagnosis of CHF from 977,850 in 2009 to 901,425 in 2014. Females accounted for 49.7%. Total charges for CHF admission were highest in Asians at an average cost of $59,668. African Americans had the lowest mortality rate at 1.75%, however, they also had an average age of admission of 63.47 years, compared to Caucasian at 76.76 (p<0.05). Total charges for males were $42,920 and $36,744 for females (p <0.05). Males also had more procedures at 1.16 vs 0.98 for females (p <0.05). Elixhauser mortality score was higher in males than females at 5.95 vs 5.42 (p <0.05). Conclusion Healthcare disparities exist in CHF admissions in both contexts of race and gender. Further studies are required to pinpoint the source of these differences not only to address mortality but also expenditure costs.

Three femoral fixation devices for anterior cruciate ligament reconstruction: comparison of fixation on the lateral cortex versus the anterior cortex.

PURPOSE: To evaluate the biomechanical properties of 3 anterior cruciate ligament (ACL) reconstruction femoral fixation devices in a porcine model with implantation on both the lateral femoral cortex and the anterior femoral cortex. METHODS: ACL reconstructions with an 8-mm porcine tendon graft were performed on 48 porcine femurs with the EndoButton CL (Smith & Nephew, Andover, MA), ToggleLoc with ZipLoop technology (Biomet Sports Medicine, Warsaw, IN), or EZLoc (Biomet Sports Medicine). In 8 specimens for each implant, the femoral tunnel was drilled from the 10:30 surgical position out the lateral cortex. In another 8 specimens for each implant, the tunnel was drilled from the 10:30 position to a standardized anterior femoral surface. Cyclic testing was performed on an MTS testing machine (MTS, Eden Prairie, MN) from 50 N to 450 N for 2,000 cycles, followed by load-to-failure testing in specimens that survived. The cortical thickness and location of the implant exit were recorded. RESULTS: In the lateral femur group, 0 of the EZLoc devices, 2 of the ToggleLoc devices, and 3 of the EndoButtons completed cyclic testing. In the anterior femur group, 1 of the EZLoc devices, 5 of the ToggleLoc devices, and 5 of the EndoButtons completed cyclic testing (P = .012). In the anterior femur group, the ToggleLoc exhibited higher 2,000-cycle elongation (5.46 +/- 1 mm) than the EndoButton (3.55 +/- 0.6 mm) (P = .005). The EndoButton showed a higher first failure load (1,190.9 +/- 150.0 N) than the ToggleLoc (912.6 +/- 82.4 N) (P = .007). The anterior cortex (1.4 mm) was thinner than the lateral cortex (1.7 mm) (P = .0002). CONCLUSIONS: The EndoButton provided the strongest ACL femoral fixation with significantly less graft-implant elongation and significantly higher failure loads. It was also shown in a porcine model that implants on the anterior cortical surface perform better than those on the lateral surface. Increased cortical thickness, in the range tested, was not associated with improved implant performance in the porcine model. CLINICAL RELEVANCE: The EndoButton provided the best ACL femoral fixation of the devices tested.

Tensioning of anterior cruciate ligament hamstring grafts: comparing equal tension versus equal stress.

PURPOSE: A biomechanical study was undertaken to determine whether equal-stress or equal-tension tensioning of anterior cruciate ligament 4-stranded semitendinosus and gracilis grafts provides a stronger graft construct when testing to ultimate failure. METHODS: Eighteen fresh-frozen cadaveric semitendinosus and gracilis tendons were each positioned over a cylinder rod/cryo-clamp connected to an MTS machine (MTS Systems, Eden Prairie, MN) by another cryo-clamp. In the equal-tension group the 4 strands were equally tensioned by weights. In the equal-stress group a tensioning device applied equal stress based on the cross-sectional areas of the tendons. The tendons were preconditioned with 10 cycles and then tested to failure. Graft creep during the preconditioning cycle was determined by MTS measurement of the change in clamp distance. RESULTS: The maximum loads of 4-stranded semitendinosus and gracilis grafts tensioned by equal stress were found to be similar to those of the grafts tensioned by equal tension (2,803 +/- 431 N and 2,772 +/- 461 N, respectively). The loads at first failure were 2,640 +/- 468 N and 2,452 +/- 461 N, respectively (P = .17). The preconditioning cycles showed that the equal-stress group resisted graft creep significantly better (P = .0003). CONCLUSIONS: The strength of the 4-stranded hamstring graft when equally tensioned or equally stressed was equivalent when tested to failure. After 10 preconditioning cycles, equal stress resisted graft creep significantly better. Equal-stress tensioning offers an alternative tensioning method for 4-stranded hamstring grafts. CLINICAL RELEVANCE: Equal-stress tensioning offers an alternative tensioning method for 4-stranded hamstring grafts.