Filippo Prestipino

Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting

Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.

Nickel Allergy Induced Systemic Reaction to an Intracardiac Amplatzer Device

Nickel hypersensitivity is reported in about 10–15% of the general population and manifests mainly with dermatological signs. Chest discomfort, palpitations, signs and symptoms of pericarditis, and migraine are symptoms reported in rare cases of nickel hypersensitivity after implantation of a cardiac device made of nickel. We present the case of a patient with a nickel allergy from an Amplatzer device in which the removal of the device produced resolution of the symptoms. doi: 10.1111/jocs.12331 (J Card Surg 2014;29:349–350)

Ventricular perforation by pacemaker lead repaired with two hemostatic devices

INTRODUCTION Cardiac perforation is a rare, but potentially serious, complication of pacemaker implantation that may develop days or weeks after implantation. PRESENTATION OF CASE In the current case, 92-year-old man underwent permanent pacemaker implantation, but he presented 3 weeks later with severe symptoms. Computed tomography showed protrusion of the tip of the ventricular electrode through the right ventricle and into the chest wall. During an urgent surgical intervention, the lead was disconnected and extracted. A sealing hemostatic device and an hemostatic patch were applied to repair the ventricle; the procedure was uneventfull. DISCUSSION This case demonstrates how the correct diagnosis of ventricular perforation is crucial, and should be followed immediately by surgical planning. CONCLUSION The hemostatic patch is a valuable alternative to sutures in patients with thin and fragile ventricular wall, unable to undergo stitching.

Off-pump coronary artery bypass grafting versus optimal medical therapy alone: effectiveness of incomplete revascularization in high risk patients

Background Geriatric patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy. Methods We retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included: 42 were treated with incomplete off-pump revascularization using left internal mammary artery (LIMA) on LAD; 41 were discharged in optimal medical therapy (OMT), having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events (MACEs). Results During follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank < 0.001), and OMT group carries a propensity score-adjusted hazard ratio of 3.862 (P < 0.001). With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT (Log Rank = 0.002), and OMT group carries a propensity score-adjusted hazard ratio of 3.663 (P = 0.010). There is no statistically significant difference concerning freedom from MACEs (Log Rank = 0.273). Conclusions For high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.

Coronary arterovenous fistula: to treat or not to treat?

We reported the case of a 68-year old male with chest pain. The coronary angiography showed the disease of the left anterior descending coronary artery and, incidentally, an arteriovenous coronary fistula between this coronary branch and the pulmonary artery. The patient underwent off-pump coronary bypass through a left mini thoracotomy. In the present case, after a series of detailed exams, we decided not to close the fistula for several reasons, but mainly because of the singular localization of an atherosclerotic plaque proximal to the origin of the fistula. Therefore, under specific conditions, it may not always be mandatory to close the coronary arteriovenous fistulas.

Unconventional location for a cardiac lipoma: The anterior papillary muscle

Primary cardiac tumors are uncommon, and lipoma is the second most frequent benign type after myxoma. The treatment of choice is surgery, with the complete excision of the mass. Nevertheless, in the absence of symptoms and clinical signs the indication for surgery is less defined, and close follow up may be recommended. In the case we are going to report the patient was followed by periodical clinical and echographic examination, always reconsidering the possibility of treatment. <Learning objective: Cardiac lipoma is a tumor with different possible locations in the cardiac tissue and with different possible clinical patterns; in the presence of a cardiac lipoma the treatment of choice is surgery. The presence of a cardiac mass suggests investigating it with a high-resolution image examination, and to strictly follow the patient over time.>.

Preoperative aspirin continuation versus replacement therapy with low molecular weight heparin before coronary surgery: effects on postoperative bleeding risk

Management of preoperative antiplatelet therapy in coronary surgery is still variable among surgeons. Guidelines collide with prejudices: replacement of aspirin with low molecular weight heparin (LMWH) is still performed in many Centers due to a presumed minor risk of intraoperative bleeding, even though supporting evidences are weak and detrimental effects are well-described.

Off-pump coronary artery bypass grafting versus optimal medical therapy: effectiveness of incomplete surgical myocardial revascularization in high-risk patients with multi-vessel coronary artery disease

High-risk patients with multivessel disease (MVD) represent a surgical challenge carrying high mortality risk. These cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Off-pump coronary artery bypass (OPCAB) provides good quality graft on left anterior descending (LAD) without exposing the patient to cardiopulmonary bypass, and, despite providing an incomplete revascularization, might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures.

Severe stenosis of left coronary artery originating from right sinus of Valsalva treated with off-pump coronary artery bypass surgery

Anomalous origin of the left coronary artery originating from the opposite sinus of Valsalva is a coronary anomaly with a consistently low prevalence rate. Different patterns have been described for this type of anomaly with respect to the position and course of the coronary arteries. The interarterial type can be considered a malignant variant, as it is characterized by a left main coronary artery that is positioned between the aortic root and the pulmonary artery root, and it frequently presents with syncope or aborted sudden cardiac death. Other symptoms or clinical presentations include the presence or development of angina, acute myocardial infarction and ventricular tachycardia. We present the case of a 49-year old man who presented with a new onset of chest pain; a coronary angiogram showed an anomalous left main coronary artery arising from the right Valsalva sinus, accompanied by a long and severe stenosis. It was found that multi-scan cardiac tomography is very useful in identifying the position of the coronary arteries when coronary anomalies occur.