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Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is a mainstay of the prevention of stent thrombosis following percutaneous coronary intervention (PCI). In the 2015 European guidelines for the management of acute coronary syndrome (ACS), prasugrel (PRA) and ticagrelor (TICA) combined with aspirin are recommended as first-line therapy. Clopidogrel (CLO) is recommended as an alternative medication for patients with contradictions to these new drugs. This single-center study analyzed the platelet function of 809 ACS patients undergoing PCI and treatment with DAPT. The platelet response to ADP was determined using Multiplate® analyzer at a median of 3 days after PCI in 254 patients treated with PRA (loading dose [LD] 60 mg, 10 mg qd), 162 patients receiving TICA (LD 180 mg, D 90 mg bid), and 393 CLO-treated patients (LD 600 mg, 75 mg qd). An aggregation >468 arbitrary units (AU)*min was defined as "high on-treatment platelet reactivity" (HPR), <188 AU*min as "low on-treatment platelet reactivity" (LPR). Platelet response in PRA-treated patients was lower compared to CLO or TICA (median; interquartile range: PRA 220 [163-275] AU*min vs. CLO 268 [186-387] AU*min, p < 0.001 vs. TICA 245 [190-320] AU*min, p = 0.001). Only 1.6% of PRA patients were stratified as HPR and 34.6% as LPR, while in the TICA group 1.9% fulfilled the criteria of HPR and 24.1% criteria of LPR. Sixteen percent of CLO patients were stratified as HPR and 26.2% as LPR. In a real-world cohort of ACS patients following PCI, PRA results in more potent inhibition of platelet function compared to CLO and TICA. TICA achieves a consistent antiplatelet effect with reduced rates of HPR and LPR in relation to CLO. [ABSTRACT FROM AUTHOR]

Background The occurrence of severe carotid artery disease in more than 12% of patients requiring coronary artery bypass grafting (CABG) results in a discrepancy concerning best treatment for both diseases. We reviewed the early outcome of patients with CABG and/or valve replacement (VR) and simultaneous carotid endarterectomy (CEA). Methods We retrospectively evaluated 386 patients after simultaneous operation between 7/1994 and 9/2010. Total 326 patients received isolated CABG, 56 CABG and/ or VR, 4 aortic surgery. Mean age was 68.3 years (range: 45 to 87). Male patients were 229. Severity of stenosis at operated side was 70 to 80% in 167, 80 to 99% in 219 patients. Total 164 patients showed bilateral carotid stenosis, 32 had contralateral occlusion. We analyzed risk factors, morbidity, incidence of neurological events, and 30-day mortality. Results Perioperative stroke with hemiplegia occurred in 10 patients (2.6%). Three patients experienced PRIND, seven TIA. A 30-day mortality was 5.2%. Total 8 deaths were cardiac related, 10 due to extracardial reasons, and 2 patients developed a cerebral death. Conclusions Simultaneous CEA and cardiac surgery can be performed with a low risk for neurological complications and acceptable mortality. Occlusion of contralateral carotid artery could be identified as an evident predictor for increased neurological complications. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Superior patency of internal thoracic artery (ITA) grafting to saphenous veins is conclusive. The aim of the present study was to compare the early outcome of patients receiving either bilateral ITA (BITA) or single ITA (SITA) grafts and to identify risk factors for perioperative complications, such as obesity, diabetes mellitus, or advanced age. Methods: All 8666 patients with isolated coronary artery bypass grafting (CABG, including emergent cases or redos) operated between January 1994 and June 2004 receiving either BITA (n =4462) or SITA (n =4204) grafting were analyzed retrospectively. Demographic data were comparable for both groups concerning mean age (65.3±9.4 years vs 64.9±9.3 years), range (35–89 years (p =0.05)), diabetes incidence (29.3% vs 2.6% (p =0.08)), dialysis-dependent renal failure (0.7% vs 0.6% (p =0.4)), preoperative ejection fraction (EF) mean (61.8% vs 61.2% (p =0.07)) but not for gender (80.4% vs 76.7% males (p =0.00)), body mass index (BMI) mean (27.2±3.6 vs 26.9±3.5 (p =0.00)), COPD (7.0% vs 8.5% (p =0.00)), and hyperlipidemia (78.3% vs 74.3% (p =0.00)). In the BITA group, right ITA (RITA) was directed preferentially to the left anterior descending artery (LAD), left ITA (LITA) to the lateral wall. In the SITA group, the LAD was revascularized with the left ITA. Additional bypasses were performed with saphenous vein grafts (SVG). Results: The number of anastomoses was higher in the BITA group (3.8±0.9 vs 3.1±0.9 (p =0.00)); therefore, duration of surgery (mean: 189±46.3min vs 164±46.2min) and cross-clamp time (62.0±17.9min vs 51.0±18.0min) significantly prolonged (p =0.00). Incidence of rethoracotomy due to bleeding (2.9% vs 0.6%; p =0.00) or sternal refixation with (0.7% vs 0.2%; p =0.00) or without infection (1.4% vs 0.6%; p =0.00) was higher in the BITA group, strongly associated with diabetes mellitus and duration of surgery but not with BMI>27. Thirty-day mortality revealed 2.6% versus 3.2% (p =0.1) but was significantly lower for diabetic patients in the BITA group (3.1% vs 4.7%; p =0.00). Conclusions: CABG using both ITAs can be performed routinely with good clinical results and low mortality. Compared with single ITA grafting, sternal and bleeding complications were slightly increased. Diabetes mellitus, BITA grafting, duration of surgery but not obesity or COPD could be identified as independent risk factors for sternal complications. Dialysis-dependent renal failure, EF<30%, emergent cases, and the absence of BITA grafting were predictors for increased perioperative mortality. [Copyright &y& Elsevier]

Aims: To assess image quality and diagnostic performance of 3.0 Tesla (3T) cardiac magnetic resonance (CMR) myocardial perfusion imaging with a dual radiofrequency source to detect functional relevant coronary artery disease (CAD), using coronary angiography and invasive pressure-derived fractional flow reserve (FFR) as reference standard., Methods and Results: We included 116 patients with suspected or known CAD, who underwent 3T adenosine myocardial perfusion CMR (resolution 2.97 × 2.97 mm) and coronary angiography plus FFR measurements in intermediate lesions. Image quality of myocardial perfusion CMR was graded on a 4-point scale (1 = poor to 4 = excellent). Diagnostic accuracy was assessed by ROC analyses using a 16-myocardial segment-based summed perfusion score (0 = normal to 3 = transmural perfusion defect) and by determining sensitivity, specificity, positive and negative predictive value on the coronary vessel territory and the patient level. Diagnostic image quality was achieved for all stress myocardial perfusion CMR studies with an average quality score of 2.5, 3.1, and 3.0 for LAD, LCX, and RCA territories. The ability of the myocardial perfusion CMR perfusion score to detect significant coronary artery stenosis yielded an area under the curve of 0.93 on ROC analysis. Values for sensitivity, specificity, positive and negative predictive value on a vessel territory level and the patient level were 89, 95, 87, 96% and 85, 87, 77, 92%, respectively., Conclusion: In patients with suspected or known significant CAD, 3T myocardial perfusion CMR with standard perfusion protocols provides consistently high image quality and an excellent diagnostic performance.

Background: Nonhepatic cancer risk of cirrhotic patients seems to be increased. Major surgery and chemotherapy in cirrhosis are associated with increased mortality and morbidity, which limits treatment., Aim: The aims of this study were analysis of (a) prevalence, (b) outcome after treatment, (c) of survival rate and (d) predictors of survival in a cirrhotic population., Patients and Methods: The study population was assembled retrospectively from a database of hospitalized patients (n=354). The Kaplan-Meier method was used to calculate the survival rate, and Cox regression analysis was performed to identify prognostic parameters., Results: Altogether, 84 neoplasms in 70 patients were observed. A total of 54 were nonhepatic (15.3%) mainly colorectal carcinoma, prostate cancer and tobacco-related neoplasms. TNM stage was the best prognostic parameter (p<0.0001). Low bilirubin (p=0.01), normal albumin (p=0.005) and absence of ascites (p<0.0001) were also related significantly to longer survival. The rate of postinterventional death after specific treatment was high. A proportion of patients received no specific therapy due to reduced physical performance, even in cases of limited disease., Conclusion: Our data confirm the increased risk of cirrhotic patients for developing nonhepatic cancer. Advanced TNM stage was associated with reduced long-term survival. Scoring systems, such as Child's classification and Model of Elevated Liver Disease (MELD) score, were suitable parameters to predict mortality. Oncological management in patients with cirrhosis must be on an individual basis, independent from TNM classification.