Surgical revascularization in stable coronary artery disease with ventricular dysfunction: a single-center cohort study.

PURPOSE: Stress-gated myocardial perfusion scintigraphy (MPS) is used for prognosis in stable coronary artery disease (CAD). We sought to assess coronary artery bypass grafting (CABG) outcomes in stable coronary artery disease patients who had myocardial perfusion scintigraphy and left ventricular (LV) dysfunction. METHODS: Stable CAD patients who underwent CABG (2012-2019) and had stress-gated MPS were identified retrospectively. Based on the post-stress LV ejection fraction, a total of 130 patients were divided into a control group (51%) and LV dysfunction group (49%). RESULTS: Patients with left ventricular dysfunction had significantly more mean summed stress score (22.1 ± 9 Vs. 12.5 ± 8; P ≤ 0.001) and summed resting score (14.6 ± 8 Vs. 3.7 ± 4; P ≤ 0.001) compared to the control group respectively. They also had a greater risk for developing low cardiac output syndrome after surgery (OR: 2.9, 95% CI 1.1-6.6, P=0.033). At 4.7 years, freedom from cardiac death was not statistically significant between the left ventricular dysfunction and control groups, respectively (90.2% vs. 95.6%; P=0.157). Cardiac death was not influenced by either ventricular dysfunction at the time of surgery (HR: 2.6, 95% CI 0.64-10.6, P=0.182) nor by having percent ischemic myocardium > 10% (HR: 0.86, 95% CI 0.23-3.24, P=0.826). CONCLUSION: Significant myocardial ischemia and ventricular dysfunction before complete surgical revascularization did not influence the risk of cardiac-related deaths on long-term follow-up. This might be related to the improved survival after CABG in patients with myocardial ischemia and left ventricular dysfunction.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

OBJECTIVES: The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. INTERVENTIONS: Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. MEASUREMENTS AND MAIN RESULTS: Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). CONCLUSIONS: Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Documentation of various approaches and outcomes in patients on warfarin undergoing dental procedures: a review article.

Appropriate management of patients with mechanical prosthetic valves on warfarin during dental procedures is crucial. If the patients continue warfarin, they might develop bleeding, while interruption of therapy can cause thromboembolic events. Bridging therapy (mostly heparin) is used in some patients, while others stop medications. There is no unifying protocol. Information on management of patients on warfarin undergoing dental procedures in Saudi Arabia is lacking. Therefore, the current study aimed to provide more insight into various approaches utilized by clinicians to deal with such patients at a large teaching hospital in Riyadh, and to evaluate the frequency and severity of bleeding and thromboembolic complications during different types of dental procedures in this population. This was a cohort study. Patient records were used to collect data on peri-procedural management of patients on warfarin, continuation or interruption of warfarin therapy, as well as bleeding and thromboembolic complications. Fifty medical records were reviewed from March to October 2012. Regarding management, 10% had no proper documentation, 74% underwent bridging therapy, 12% discontinued warfarin therapy, and 4% continued warfarin. Of the patients, 31% had minor bleeding (15% in patients on bridging therapy and 16% in patients continuing warfarin). Thromboembolic complications were documented in 4%, (2% in those on bridging therapy and 2% in those discontinuing warfarin). Patients on bridging therapy (heparin) were admitted to the hospital for a mean of five days, and none of the other patients were admitted. Adopting the protocol to continue warfarin caused bleeding tendency that was controlled with the usual measures, with more cost effectiveness, and no thromboembolic risks.