Alain Delabays

Urological surgery and antiplatelet drugs after cardiac and cerebrovascular accidents.

PURPOSEnThe perioperative treatment of patients on dual antiplatelet therapy after myocardial infarction, cerebrovascular event or coronary stent implantation represents an increasingly frequent issue for urologists and anesthesiologists. We assess the current scientific evidence and propose strategies concerning treatment of these patients.nnnMATERIALS AND METHODSnA MEDLINE and PubMed search was conducted for articles related to antiplatelet therapy after myocardial infarction, coronary stents and cerebrovascular events, as well as the use of aspirin and/or clopidogrel in the context of surgery.nnnRESULTSnEarly discontinuation of antiplatelet therapy for secondary prevention is associated with a high risk of coronary thrombosis, which is further increased by the hypercoagulable state induced by surgery. Aspirin has recently been recommended as a lifelong therapy. Clopidogrel is mandatory for 6 weeks after myocardial infarction and bare metal stents, and for 12 months after drug-eluting stents. Surgery must be postponed beyond these waiting periods or performed with patients receiving dual antiplatelet therapy because withdrawal therapy increases 5 to 10 times the risk of postoperative myocardial infarction, stent thrombosis or death. The shorter the waiting period between revascularization and surgery the greater the risk of adverse cardiac events. The risk of surgical hemorrhage is increased approximately 20% by aspirin and 50% by clopidogrel.nnnCONCLUSIONSnThe risk of coronary thrombosis when antiplatelet agents are withdrawn before surgery is generally higher than the risk of surgical hemorrhage when antiplatelet agents are maintained. However, this issue has not yet been sufficiently evaluated in urological patients and in many instances during urological surgery the risk of bleeding can be dangerous. A thorough dialogue among surgeon, cardiologist and anesthesiologist is essential to determine all risk factors and define the best possible strategy for each patient.

Very long-term follow-up after percutaneous closure of patent foramen ovale

AIMSnTo evaluate the very long-term risk of recurrent thromboembolic events in patients treated by percutaneous PFO closure.nnnMETHODS AND RESULTSnBetween 1998 and 2008, a total of 232 consecutive patients with PFO and a high suspicion of paradoxical embolism were treated by percutaneous closure. The following major events were observed during hospitalisation: implantation failure (one patient) and appearance of an acute left-sided device thrombus requiring surgery (one patient). The primary endpoint of the study was a recurrent embolic event beyond at least five years follow-up. During a mean follow-up of 7.6±2.4 years, this event occurred in five patients, representing a 0.28% annual/patient risk. Other major complications during follow-up were the following: late thrombus formation on the device (two patients) and transient atrial fibrillation (15 patients). Three patients died during follow-upxa0from cardiovascular causes considered not related to the index procedure. The PFO was judged closed on follow-up echocardiography in 92.3% of patients.nnnCONCLUSIONSnLong-term follow-up following percutaneous PFO closure for presumed paradoxical embolism reveals very low recurrence rates. This observation should be put in perspective with recent published randomised trials comparing percutaneous closure and medical therapy.

Beating heart coronary artery surgery: is sternotomy a suitable alternative to minimal invasive technique?

OBJECTIVESnTo evidence the respective advantages and drawbacks of minimal invasive-thoracotomy (MIDCAB) and off-pump sternotomy (OPCAB) coronary bypass techniques.nnnMETHODSnThe perioperative and mid-term (3 months) results of the first 31 MIDCABs and 39 OPCABs performed by a single experienced coronary surgeon (F.S.) were compared. Differences were assessed by two-tailed chi-square or unpaired t-test, and significance assumed for P-values < or =0.05.nnnRESULTSnGroups were widely comparable. There were no in-hospital deaths nor permanent neurologic events. OPCAB patients received more anastomoses (mean 1.09/patient vs. 1.89/patient, P<0.001) during a shorter coronary occlusion period (26.1+/-8 vs. 16.6+/-4.5min, P<0.001), whilst immediate extubation prevailed in MIDCABs (22/31 vs. 17/39, P<0.05). Significant complications occurred in seven MIDCABs vs. none in OPCABs (P<0.01). Other in-hospital parameters were similar. Controls at 3 months evidenced more residual discomfort among MIDCAB patients (14/30 vs. 7/39, P<0.05).nnnCONCLUSIONSnDifferences in early complication rates may be due to a learning effect. However, OPCAB allows us to implant more grafts and is more comfortable for both patient and surgeon. These advantages may well counterbalance the cosmetic benefits of MIDCAB procedures.

Percutaneous closure of a paravalvular leak 4 years after mitral valve replacement

An 89-year-old man presented with global cardiac insufficiency 4 years after mitral valve replacement by a 29 mm St Jude mechanical valve for severe mitral insufficiency. In the immediate post-operative period, a mild paravalvular leak had been noted and increased progressively from 0.13 to 0.38 cm2 actually ( Panel A ).nnBecause of the very active status of the …

Caught in the act

A 59-year-old woman presented with acute pulmonary embolism. A routine echocardiography showed pulmonary hypertension, right ventricular dysfunction and a mass floating in the left atrium (Fig. 1). Numerous clots could also be removed from the left pulmonary artery (Fig. 2). An inferior vena cava filter was inserted post-operatively and the patient recovered uneventfully. At the 6 months follow-up visit, she was asymptomatic. European Journal of Cardio-thoracic Surgery 14 (1998) 516