Anders Jeppsson

2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

Authors/Task Force Members: Marco Valgimigli* (Chairperson) (Switzerland), Héctor Bueno (Spain), Robert A. Byrne (Germany), Jean-Philippe Collet (France), Francesco Costa (Italy), Anders Jeppsson (Sweden), Peter Jüni (Canada), Adnan Kastrati (Germany), Philippe Kolh (Belgium), Laura Mauri (USA), Gilles Montalescot (France), Franz-Josef Neumann (Germany), Mate Petricevic (Croatia), Marco Roffi (Switzerland), Philippe Gabriel Steg (France), Stephan Windecker (Switzerland), and Jose Luis Zamorano (Spain)

2017 EACTS Guidelines on perioperative medication in adult cardiac surgery

Authors/Task Force Members: Miguel Sousa-Uva* (Chairperson) (Portugal), Stuart J. Head (Netherlands), Milan Milojevic (Netherlands), Jean-Philippe Collet (France), Giovanni Landoni (Italy), Manuel Castella (Spain), Joel Dunning (UK), T omas Gudbjartsson (Iceland), Nick J. Linker (UK), Elena Sandoval (Spain), Matthias Thielmann (Germany), Anders Jeppsson (Sweden) and Ulf Landmesser* (Chairperson) (Germany)

Platelet function recovery after ticagrelor withdrawal in patients awaiting urgent coronary surgery

ObjectivenDual antiplatelet therapy with ticagrelor and aspirin is associated with an increased risk of perioperative bleeding complications. Current guidelines recommend therefore discontinuation of ticagrelor 5 days before surgery to allow sufficient recovery of platelet function. It is not known how the time to recovery varies between individual patients after discontinuation of ticagrelor.nnnMethodsnTwenty-five patients accepted for urgent coronary artery bypass surgery and treated with ticagrelor and aspirin were included in a prospective observational study. Platelet aggregation was evaluated with impedance aggregometry at five timepoints 12-96u2009h after discontinuation of ticagrelor. In a subset of patients ( n u2009=u200915), we also tested the ex vivo efficacy of platelet concentrate supplementation on platelet aggregation.nnnResultsnThere was a gradual increase in mean adenosine diphosphate-induced platelet aggregation after discontinuation of ticagrelor. After 72u2009h, mean aggregation was 38u2009±23 aggregation units (U), which is above a previously suggested cut-off of 22u2009U, when patients can be operated without increased bleeding risk. However, there was a large interindividual variability (range 4‒88u2009U at 72u2009h) and 6/24 patients (25%) hadu2009<22u2009U after 72u2009h. Ex vivo administration of platelet concentrate did not improve adenosine diphosphate-induced aggregation at any timepoint after ticagrelor discontinuation.nnnConclusionsnAdenosine diphosphate-induced aggregation was acceptable after 72u2009h in the majority of patients but with a large interindividual variability. Due to the large variability, platelet function testing may prove to be a valuable tool in timing of surgery in patients with ongoing or recently stopped ticagrelor treatment. Adenosine diphosphate-induced aggregation was not improved by addition of platelet concentrate.

Surgical treatment for isolated mitral valve endocarditis: a 16-year single-centre experience

OBJECTIVESnDespite progress in management, mitral valve endocarditis (MVE) is still a life-threatening disease. We report our experience in surgical treatment of infective isolated MVE.nnnMETHODSnA total of 140 operations in 128 patients for MVE performed between January 2000 and December 2015 were included in a retrospective study. There were 109 (78%) operations for native and 31 (22%) operations for prosthetic valve endocarditis. Preoperative and postoperative characteristics and mortality of patients were registered. Cox regression identified factors associated with mortality. Mean follow-up period was 68u2009months (range 1-168u2009months) and 100% complete.nnnRESULTSnThere were 13 deaths within 30u2009days after the 140 operations (9%). Severe perioperative complications occurred in 59 (42%) operations. Overall cumulative survival was 73%u2009±u20094 at 5u2009years and 62u2009±u20095% at 10u2009years after the first operation. Age, diabetes, EuroSCORE II and perivalvular abscess were independent predictors for long-term mortality. Valve repair was performed in 76 (54%) operations and replacement in 64 (46%) operations. Thirty-day mortality for repair was 1%, and 5-year and 10-year cumulative survival was 86u2009±u20094% and 77u2009±u20096%, respectively. In the replacement group the 30-day mortality was 19% and cumulative survival at 5u2009years and 10u2009years was 55u2009±u20097% and 41u2009±u20098%, respectively. Postoperative complications occurred in 21% and 67%, respectively, after operations for repair and replacement. Ten (8%) patients had 12 reoperations for recurrent endocarditis.nnnCONCLUSIONSnMVE requiring surgical treatment is a challenging disease with high hospital mortality after valve replacement. Mitral valve repair can be performed in suitable endocarditis patients with excellent results. Age, diabetes and EuroSCORE were independently associated with mortality in a multivariable model.

2017 European Society of Cardiology (ESC) focused update on dual antiplatelet therapy in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).

a Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden b Department of Cardiac Surgery, School of Medicine, University of Zagreb, University Hospital Center Zagreb-Rebro, Zagreb, Croatia c Department of Biomedical and Preclinical Sciences, University Hospital (CHU, ULg) of Liège, Liège, Belgium d Department of Cardiology, Inselspital Universitätsspital Bern, Bern, Switzerland

The 2017 EACTS guidelines on perioperative medication in adult cardiac surgery and patient blood management

a Department of Cardiac Surgery, Hospital de Santa Cruz, Carnixade, Portugal b Departamento de Cirurgia e Fisiologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal c Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands d Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

The Effect of Ex Vivo Factor XIII Supplementation on Clot Formation in Blood Samples From Cardiac and Scoliosis Surgery Patients

Excessive perioperative bleeding remains a substantial problem. Factor XIII (FXIII) contributes to clot stability, and it has therefore been suggested that supplementation with FXIII concentrate may improve perioperative hemostasis. We evaluated the effects of increasing doses of FXIII, alone or in combination with fibrinogen or platelet concentrate, in blood samples from 2 considerably different groups of surgical patients: cardiac and scoliosis surgery patients. Whole-blood samples were collected immediately after operation from cardiac and scoliosis surgery patients. The samples were supplemented with 3 clinically relevant doses of FXIII concentrate (+20%, +40%, and +60%), alone or in combination with a fixed dose of fibrinogen concentrate (+1.0 g/L) or fresh apheresis platelets (+92 × 109/L). Clot formation was assessed with rotational thromboelastometry (ROTEM). When the highest dose of FXIII concentrate was added, EXTEM clotting time was shortened by 10% in both cardiac and scoliosis surgery patients (95% confidence intervals: 2.4%-17% and 3.3%-17%, respectively), and FIBTEM maximum clot firmness was increased by 25% (9.3%-41%) in cardiac patients, relative to baseline. When fibrinogen was added, the dose-dependent effect of FXIII on clot stability was maintained, but the total effect was markedly greater than with FXIII alone, +150% (100%-200%) and +160% (130%-200%) for the highest FXIII dose in cardiac and scoliosis patients, respectively. Ex vivo supplementation with clinically relevant doses of FXIII improved clot formation moderately in blood samples from cardiac and scoliosis surgery patients, both alone and when given in combination with fibrinogen or platelet concentrate.

Platelet storage lesion in interim platelet unit concentrates: A comparison with buffy-coat and apheresis concentrates

Platelet storage lesion is characterized by morphological changes and impaired platelet function. The collection method and storage medium may influence the magnitude of the storage lesion. The aim of this study was to compare the newly introduced interim platelet unit (IPU) platelet concentrates (PCs) (additive solution SSP+, 40% residual plasma content) with the more established buffy-coat PCs (SSP, 20% residual plasma content) and apheresis PCs (autologous plasma) in terms of platelet storage lesions. Thirty PCs (n=10 for each type) were assessed by measuring metabolic parameters (lactate, glucose, and pH), platelet activation markers, and in vitro platelet aggregability on days 1, 4, and 7 after donation. The expression of platelet activation markers CD62p (P-selectin), CD63 (LAMP-3), and phosphatidylserine was measured using flow cytometry and in vitro aggregability was measured with multiple electrode aggregometry. Higher platelet activation and lower in vitro aggregability was observed in IPU than in buffy-coat PCs on day 1 after donation. In contrast, metabolic parameters, expression of platelet activation markers, and in vitro aggregability were better maintained in IPU than in buffy-coat PCs at the end of the storage period. Compared to apheresis PCs, IPU PCs had higher expression of activation markers and lower in vitro aggregability throughout storage. In conclusion, the results indicate that there are significant differences in platelet storage lesions between IPU, buffy-coat, and apheresis PCs. The quality of IPU PCs appears to be at least comparable to buffy-coat preparations. Further studies are required to distinguish the effect of the preparation methods from storage conditions.

Predisposing Factors for Re-interventions with Additional Iliac Stent Grafts After Endovascular Aortic Repair

BACKGROUNDnEndoleaks of type Ib and III are relatively common causes of re-intervention after EVAR. The aim was to determine underlying causes and identify anatomical factors associated with these re-interventions.nnnMETHODSnA total of 444 patients with standard bifurcated stent grafts were included in a retrospective observational study. Patients requiring additional iliac stent grafts (nxa0=xa024) were compared to those who did not (nxa0=xa0420). Pre- and post-operative CT examinations were reviewed in patients with additional iliac stents. Reasons for re-interventions were defined as migration (>5xa0mmxa0at the distal end or at interconnections), progression of disease (iliac artery diameter exceeding graft diameter), inadequate distal seal length at primary repair, or a combination of these factors.nnnRESULTSnTwenty-four patients received 31 additional grafts in 30 limbs after a median 46 months (range 2-92 months). Five re-interventions (21%) were due to rupture. Re-intervened limbs had a larger iliac artery diameter 18xa0mm (25th and 75th percentile 20-25) versus 15xa0mm (13-18xa0mm), pxa0<xa0.001. The degree of iliac limb oversizing at primary EVAR was lower in re-intervened patients (11% (8-18%) versus 18% (12-26%), pxa0=xa0.003). In re-intervened patients, iliac attachment zones were shorter in treated limbs than in untreated 23xa0mm (11-34) versus 34xa0mm (25-44), pxa0<xa0.001). Sixteen of 31 re-interventions (51%) were caused by migration (10xa0at the distal landing site, 6xa0at interconnections), nine of 31 (29%) by disease progression, and nine of 31 (29%) had inadequate initial stent graft placement. Three of 31 re-interventions (10%) were done as proactive procedures.nnnCONCLUSIONSnAdditional iliac stent grafting occurred late after primary repair; a considerable number were caused by rupture. A low degree of oversizing, migration at the distal landing site, separation of stent graft interconnections, disease progression at the distal landing site, and inadequate initial stent graft placement may all contribute. Patients with large iliac dimensions and short attachment zones may need a larger degree of oversizing and more vigorous surveillance.