Search

Background and Aims The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Methods Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index–linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW). Results A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting–adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45–0.79, P =.001] over a median follow-up period of 4.0 (inter-quartile range 2.2–6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41–4.96, P =.58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21–91.6, P <.001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00–4.28, P <.001) in patients treated with CABG. Conclusions In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits. [ABSTRACT FROM AUTHOR]

Background and Aims Uncertainty exists over whether multiple arterial grafting has a sex-related association with survival after coronary artery bypass grafting. This study aims to compare the long-term survival of using multiple arterial grafting vs. single arterial grafting in women and men undergoing coronary artery bypass grafting. Methods The retrospective study used the Australian and New Zealand Society of Cardiothoracic Surgical Database with linkage to the National Death Index. Patients from 2001 to 2020 were identified. Sex-stratified, inverse probability weighted Cox proportional hazard model was used to facilitate survival comparisons. The primary outcome was all-cause mortality. Results A total number of 54 275 adult patients receiving at least two grafts in primary isolated bypass operations were analysed. The entire study cohort consisted of 10 693 (19.7%) female patients and 29 711 (54.7%) multiple arterial grafting procedures. At a median (interquartile range) postoperative follow-up of 4.9 (2.3–8.4) years, mortality was significantly lower in male patients undergoing multiarterial than single arterial procedures (adjusted hazard ratio 0.82; 95% confidence interval 0.77–0.87; P <.001). The survival benefit was also significant for females (adjusted hazard ratio 0.83; 95% confidence interval 0.76–0.91; P <.001) at a median (interquartile range) follow-up of 5.2 (2.4–8.7) years. The interaction model from Cox regression suggested insignificant subgroup effect from sex (P =.08) on the observed survival advantage. The survival benefits associated with multiple arterial grafting were consistent across all sex-stratified subgroups except for female patients with left main coronary disease. Conclusions Compared to single arterial grafting, multiple arterial revascularization is associated with improved long-term survival for women as well as men. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction Methods and Results Conclusion Substernal extravascular defibrillators (EV ICDs) have been shown to be effective and safe for patients at risk of sudden cardiac death, however, there is little evidence around the safety of extracting chronic devices.We present a 50‐year‐old patient in whom a Medtronic EV ICD system was successfully removed without specialist extraction tools, 186 weeks after implantation, by an operator experienced in transvenous lead extraction but without formal training in EVICD implantation.The successful extraction of an EV ICD system is possible without specialised tools at least 3.6 years post‐implant. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Diabetics may have diminished survival after coronary artery bypass grafting even with multiple arterial revascularization. We compared multi-arterial versus single-arterial grafting (SAG) survival in diabetic and non-diabetic patients undergoing primary isolated bypass surgery. METHODS This is a retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database from June 2001 to January 2020. Patients were classified as having either single or multiple arterial grafting irrespective of the number of venous grafts. The end points were long-term all-cause mortality and 30-day clinical outcomes, which was compared in 1:1 propensity score-matched patients. Cox regression model was used to assess interactions between diabetes and the treatment effect of multi-arterial grafting, reported as hazard ratios (HRs) and confidence intervals (CIs). Short-term outcomes were compared with McNemar's paired t -test. RESULTS From 69 624 patients, matching generated 17 474 non-diabetic and 10 989 diabetic patient pairs. At a median [interquartile range] of 5.9 [3.2–9.6] years postoperative, mortality was significantly lower after multi-arterial grafting for both diabetic (HR, 0.83; 95% CI, 0.76–0.90, P  < 0.001) and non-diabetic (HR, 0.88; 95% CI, 0.82–0.95; P  < 0.001) cohorts than SAG. The incidence of 30-day myocardial infarction was significantly higher in single than multiple arterial grafting for both cohorts (diabetic, P  = 0.029; non-diabetic, P  < 0.001). The interaction analysis suggested an insignificant effect of diabetes (P  = 0.55) on the observed survival advantage. Further stratification by diabetic management generated consistent results. CONCLUSIONS Multi-arterial grafting was associated with improved overall survival compared to SAG for both non-diabetic and diabetic patients. [ABSTRACT FROM AUTHOR]

Purpose: To assess whether pre‐operative focused cardiac ultrasound and lung ultrasound screening performed by a junior doctor can change diagnosis and clinical management of patients aged ≥65 years undergoing emergency, non‐cardiac surgery. Method: This pilot prospective observational study included patients scheduled for emergency, non‐cardiac surgery. The treating team completed a diagnosis and management plan before and after focused cardiac and lung ultrasound, which was performed by a junior doctor. Changes to diagnosis and management after ultrasound were recorded. Ultrasound images were assessed for image and diagnostic interpretation by an independent expert. Results: There was a total of 57 patients at age 77 ± 8 years. Cardiopulmonary pathology was suspected after clinical assessment in 28% vs. 72% after ultrasound (including abnormal haemodynamic state in 61%, valvular lesions in 32%, acute pulmonary oedema/interstitial syndrome in 9% and bilateral pleural effusions in 2%). In 67% of patients, the perioperative management was changed. The changes were in fluid therapy in 30%, cardiology consultation in 7%, formal in‐ or out‐patient, transthoracic echocardiography in 11% and 30% respectively. Discussion The impact of pre‐operative focused cardiac and lung ultrasound on diagnosis and management of patients on the hospital ward before emergency non‐cardiac surgery by a junior doctor was comparable to previous studies of anaesthetists experienced in focused ultrasound. However, the ability to recognise when image quality is insufficient for diagnosis is an important consideration for novice sonographers. Conclusions: Focused cardiac and lung ultrasound examination by a junior doctor is feasible and may change preoperative diagnosis and management in patients of 65 years or older, admitted for emergency non‐cardiac surgery. [ABSTRACT FROM AUTHOR]

Aim: To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients. Materials and Methods: The multinational, open‐label, randomized controlled TRICS‐III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate‐to‐high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all‐cause death, stroke, myocardial infarction, and new‐onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days. Results: Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93‐1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68‐1.59] vs. no diabetes OR 1.02 [0.85‐1.22]; Pinteraction =.92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21‐0.36]; no diabetes OR [95% CI] 0.40 [0.35‐0.47]; Pinteraction =.04). Conclusions: The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

CTLA-4 inhibitors, such as ipilimumab, and PD-1 and PD-L1 inhibitor therapy, involving pembrolizumab and nivolumab, are cornerstone for immunotherapy. The multidisciplinary team (MDT) decided that he should undergo a biopsy which would facilitate potentially new treatments including immune therapy. Cardiac metastases indicate stage IV disease; surgery is palliative and carry a poor prognosis.3 This article aims to report our institutional experience and discuss the management strategies in vogue. Melanoma is an aggressive skin malignancy and advanced stages are associated with poor survival at 1 year.1 Prognosis of metastatic melanoma (MM) was historically described in months than years. [Extracted from the article]

Blunt thoracic aortic injury (BTAI) leading to the rupture or dissection of the ascending aorta rarely present to hospital[[1]] likely due to high mortality occurring from the preceding traumatic event. A traumatic aortic injury may have an in-hospital mortality of approximately 50%.[5] Patients with aortic injury have higher in-hospital and 5-year mortality.[6] A primary repair of traumatic rupture is rare, with an interposition graft usually employed. A subsequent gated CT angiogram revealed a Type A aortic injury, with lumen irregularity in the mid ascending aorta (Fig. [Extracted from the article]

We read with interest this post-hoc analysis of the SYNTAX trial examining single arterial grafting (SAG) versus multiple arterial grafting (MAG) [[1]]. [Extracted from the article]

Aims Methods and results Conclusions The left atrial appendage (LAA) produces natriuretic peptides and its removal or occlusion might increase the risk of heart failure (HF). We aimed to investigate the incidence of HF after LAA occlusion or removal (LAAO) in the Left Atrial Appendage Occlusion Study (LAAOS III).Patients (n = 4811) with atrial fibrillation (AF) and a CHA2DS2‐VASc score ≥2, who were having cardiac surgery for another indication, were randomized to undergo surgical LAAO or not. We compared the composite outcome of HF‐related hospitalizations and HF death between the two groups. HF assessment required clinical and radiographic evidence of HF. Analyses included a landmark analysis before and after 30 days and subgroups. Mean age was 71.2 years, 67.5% were male and 57.0% had prior HF. Over a mean follow‐up of 3.8 years, 396 (8.3%) patients met the composite HF outcome: 209 (8.8%) with LAAO (n = 2379) and 187 (7.8%) without LAAO (n = 2391) (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.92–1.37, p = 0.25). There was no difference between the two groups in the first 30 days (1.6% vs. 1.1%; p = 0.12) and thereafter (7.6% vs. 7.1%; p = 0.57). Subgroups based on age, sex, body mass index, AF type, prior HF, cardiac rhythm or left ventricular ejection fraction showed consistent results. There was no difference in HF outcomes with LAAO between the cut‐and‐sew (HR 0.93, 95% CI 0.70–1.23, p = 0.62) versus other closure methods (HR 1.05, 95% CI 0.77–1.41, p = 0.77).Left atrial appendage occlusion or removal at the time of cardiac surgery does not appear to alter the risk of HF‐related hospitalization or death.Clinical Trial Registration: ClinicalTrials.gov NCT01561651. [ABSTRACT FROM AUTHOR]

Introduction: There is no consistency in current practice pertaining to the prescription and progression of upper limb resistance exercise following cardiac surgery via median sternotomy. The aim of this study is to investigate whether less restrictive sternal precautions with the addition of early-supervised resistance training exercise improves upper limb function and facilitates recovery following median sternotomy., Methods and Analysis: This is double-blind randomised controlled trial, with parallel group, concealed allocation, blinding of patients and assessors, and intention-to-treat analysis. 240 adult participants who had median sternotomy from eight hospitals in Malaysia will be recruited. Sample size calculations were based on the unsupported upper limb test. All participants will be randomised to receive either standard or early supervised incremental resistance training. The primary outcomes are upper limb function and pain. The secondary outcomes will be functional capacity, multidomain recovery (physical and psychological), length of hospital stay, incidence of respiratory complications and quality of life. Descriptive statistics will be used to summarise data. Data will be analysed using the intention-to-treat principle. The primary hypothesis will be examined by evaluating the change from baseline to the 4-week postoperative time point in the intervention arm compared with the usual care arm. For all tests to be conducted, a p value of <0.05 (two tailed) will be considered statistically significant, and CIs will be reported. The trial is currently recruiting participants., Ethics and Dissemination: The study was approved by a central ethical committee as well as the local Research Ethics Boards of the participating sites (UKM:JEP-2019-654; Ministry of Health: NMMR-50763; National Heart Centre: IJNREC/501/2021). Approval to start was given prior to the recruitment of participants commencing at any sites. Process evaluation findings will be published in peer-reviewed journals and presented at relevant academic conferences., Trial Registration Number: International Standard Randomised Controlled Trials Number (ISRCTN17842822)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)