Helena Rexius

Incomplete revascularization reduces survival benefit of coronary artery bypass grafting: role of off-pump surgery.

OBJECTIVE We sought to analyze the influence, if any, of incomplete revascularization and on/off-pump techniques on long-term mortality after coronary artery bypass grafting. METHODS A total of 9408 patients undergoing coronary artery bypass grafting, 8461 on pump and 947 off pump, operated on between 1995 and 2004 were included in the study. Adjusted hazard function for long-term mortality was estimated with Poisson regression analysis in a model that included variables reflecting completeness of revascularization, operative method (on/off pump), and background risk factors for death. RESULTS Mean follow-up after surgical intervention for survivors was 5.0 +/- 2.8 years (range, 0.5-10.5 years), with a total follow-up of 45,076 patient years. Leaving 1 diseased vascular segment without a bypass graft in 2- or 3-vessel disease did not increase the hazard ratio for death in comparison with complete revascularization (hazard ratio, 1.05; 95% confidence interval, 0.87-1.27; P = .60). In contrast, leaving 2 vascular segments without a bypass graft in 3-vessel disease was associated with an increased hazard ratio for death (hazard ratio, 1.82; 95% confidence interval, 1.15-2.85; P = .01). Incomplete revascularization was more common in the off-pump group (P < .001) in our study. If adjusting for incomplete revascularization, there was no significant influence of the use of on/off-pump techniques on the hazard ratio for death (hazard ratio, 1.08; 95% confidence interval, 0.82-1.40; P = .57). CONCLUSIONS Incomplete revascularization of patients with 3-vessel disease is an independent risk factor for increased long-term mortality after coronary artery bypass grafting. In contrast, the use of on- or off-pump techniques had no significant effect on survival after adjusting for incomplete revascularization.

One single dose of histidine–tryptophan–ketoglutarate solution gives equally good myocardial protection in elective mitral valve surgery as repetitive cold blood cardioplegia: A prospective randomized study

OBJECTIVES Histidine-tryptophan-ketoglutarate (HTK-Custodiol) cardioplegic solution is administered as one single dose for more than 2 hours of ischemia. No prospective randomized clinical study has compared the effects of HTK and cold blood cardioplegia on myocardial damage in elective mitral valve surgery. Thus, the main aim of the present study was to examine whether one single dose of cold antegrade HTK gives as good myocardial protection as repetitive antegrade cold blood cardioplegia in mitral valve surgery. METHODS Eighty consecutive patients undergoing elective isolated mitral valve surgery for mitral regurgitation, with or without ablation for atrial fibrillation, were included in the study and randomized to HTK or blood cardioplegia. Markers of myocardial injury (troponin-T and creatine kinase MB) were analyzed at baseline and 7 hours, 1 day, 2 days, and 3 days after surgery. RESULTS No significant difference in creatine kinase MB and troponin-T between HTK and blood cardioplegia groups was found at any time point. There was a significant correlation between ischemic time and markers of myocardial injury in the HTK group only and significantly more spontaneous ventricular fibrillation after release of crossclamping in the HTK group. CONCLUSIONS One single dose of antegrade cold HTK cardioplegic solution in elective mitral valve surgery protects the myocardium equally well as repetitive antegrade cold blood cardioplegia.

Extracorporeal membrane oxygenation as a bridge to lung transplantation: a long-term study

OBJECTIVES We investigated early outcomes in patients with end-stage pulmonary disease bridged with extracorporeal membrane oxygenation (ECMO) with the intention to perform lung transplantation (LTx). METHODS ECMO was used as a bridge to LTx in 20 patients between 2005 and 2013. Most patients suffered from rapid progress of disease and most failed to stabilize on mechanical ventilation. Sixteen patients (10 males, median age 42 years, range 25-59) underwent LTx after ECMO support for a median of 9 (range 1-229) days. Most patients were not on the waiting list while receiving ECMO, but after being assessed were on the waiting list for a median of 6 (range 1-72) days before LTx or death occurred. Median follow-up at 535 (range 36-3074) days was 100% complete, 9 patients have been followed for >1 year and 4 patients have been bridged during 2013. RESULTS Four patients died on ECMO waiting for a donor and as intention-to-treat, the success for bridging was 80% (16/20) and 1-year survival was 62% (10/16, not including 4 with <1-year follow-up). For those who underwent LTx, 3 patients died in-hospital after LTx on Days 0, 16 and 82, respectively, and currently, 11/16 (69%) are alive and 1-year survival for transplanted patients was 9/12 (75%). Median ICU stay before and after LTx was 9 (range 2-229) days and 20 (range 0-53) days, respectively. At follow-up, lung function was evaluated, and mean forced expiratory volume at 1 s and forced vital capacity were 56±22% of predicted and 74±24% of predicted, respectively. CONCLUSIONS ECMO used as a bridge to LTx results in acceptable survival in selected patients with end-stage pulmonary disease.

Coronary artery bypass grafting-related bleeding complications in real-life acute coronary syndrome patients treated with clopidogrel or ticagrelor

OBJECTIVES Ticagrelor reduces thrombotic events compared with clopidogrel in patients with acute coronary syndrome, but may also increase bleeding complications. Coronary artery bypass grafting (CABG)-related bleeding complications have not previously been compared in clopidogrel and ticagrelor-treated patients outside the controlled environment of clinical trials. METHODS Four hundred and five consecutive CABG patients with acute coronary syndrome were included in a prospective observational study. The patients were treated with aspirin and ticagrelor (n = 173) or aspirin and clopidogrel (n = 232). Ticagrelor/clopidogrel was discontinued 5 days before surgery whenever deemed possible. Major bleeding complications according to modified blood conservation using antifibrinolytics in a randomized trial criteria (postoperative blood loss >1500 ml/12 h, re-exploration, red blood cell transfusion >10 units or death because of bleeding) were compared in all patients and when ticagrelor/clopidogrel was discontinued ≥5 days (n = 280), 2-4 days (n = 40) or 0-1 day before surgery (n = 85). RESULTS Major bleeding complications did not differ significantly between ticagrelor- and clopidogrel-treated patients when all patients were compared (14.5 vs 13.8%, P = 0.89). Likewise, there were no significant differences between ticagrelor and clopidogrel when either drug was discontinued ≥5 days before surgery (6.8 vs 9.9%, P = 0.40) or 2-4 days before surgery (6.3 vs 25.0%, P = 0.21). When ticagrelor/clopidogrel was discontinued 0-1 day before surgery, there was a strong trend towards higher incidence of major bleeding in ticagrelor-treated patients (41.0 vs 21.7%, P = 0.063). CONCLUSIONS There was no difference in major bleeding complications overall or when ticagrelor or clopidogrel was used in accordance with guidelines. In patients on dual antiplatelet medication up to 1 day before surgery, there tended to be more bleeding complications in ticagrelor-treated patients.

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

Objective Dual 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. Methods Twenty-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 12-96 h after discontinuation of ticagrelor. In a subset of patients ( n  = 15), we also tested the ex vivo efficacy of platelet concentrate supplementation on platelet aggregation. Results There was a gradual increase in mean adenosine diphosphate-induced platelet aggregation after discontinuation of ticagrelor. After 72 h, mean aggregation was 38 ±23 aggregation units (U), which is above a previously suggested cut-off of 22 U, when patients can be operated without increased bleeding risk. However, there was a large interindividual variability (range 4‒88 U at 72 h) and 6/24 patients (25%) had <22 U after 72 h. Ex vivo administration of platelet concentrate did not improve adenosine diphosphate-induced aggregation at any timepoint after ticagrelor discontinuation. Conclusions Adenosine diphosphate-induced aggregation was acceptable after 72 h 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.

Oral and lip cancer in solid organ transplant patients--a cohort study from a Swedish Transplant Centre.

OBJECTIVES Previous large studies have shown that solid organ transplant (SOT) patients have an increased risk of developing malignancies. Few studies have compared the prognosis for SOT patients who develop cancer with that of non-transplanted cancer patients. In this study we have investigated the increased risk of oral and lip cancer in SOT patients and also compared the relative survival between SOT patients and non-SOT patients with oral and lip cancer. PATIENTS AND METHODS From the patient registers at the Transplant Institute at Sahlgrenska University Hospital, records of 4604 SOT patients from 1965 to 2010 were collected. These patient records were linked to the nationwide Swedish Cancer Register and compared to those of the normal population regarding the risk of developing oral and lip cancer, and also to non-SOT patients with lip and oral cancer. A Poisson regression model was used to compare the relative survival between SOT and non-SOT patients with oral and lip cancer. RESULTS We observed 17 oral cancers (expected 2.69) and 34 lip cancers (expected 0.78) in the cohort. The standardized incidence ratio (SIR) for oral cancer was 6.32 (95% CI, 3.7-10.1) and 43.7 (95% CI, 30.3-61.1) for lip cancer. Relative five-year survival for lip cancer was lower for SOT patients compared to non-SOT patients (p<0.001). CONCLUSION This study shows that SOT patients have a higher risk of developing both oral and lip cancer, and in addition, that SOT patients with lip cancer have a worse prognosis.

On the Allocation of Cardiac Allografts from Blood Group-O Donors

An organ allocation policy, in which hearts from blood group-O donors are used to transplant recipients with other blood groups (ABO-compatible, non-identical transplantations), may affect blood group-O patients on the waiting list. We investigated how blood group affiliation influences potential recipients on the waiting list. In the case of patients with blood group O, fewer patients were transplanted, waiting list mortality was higher and waiting time to transplantation was longer. Patients with blood group O awaiting cardiac transplantation are affected considerably by an organ allocation policy in which ABO-compatible, non-identical transplantations are performed.

Does coronary artery bypass surgery improve survival

Abstract Objectives. According to guide-lines, coronary bypass surgery improves survival in high risk patients. The evidence for this is more than 20 years old and may be questioned. Long waiting lists for coronary bypass surgery are detrimental but offer the possibility to compare the risk of death before and after surgery. We hypothesized that the risk of death is lower after bypass surgery than before the operation in high risk patients in a more recent cohort. Design and results. Death hazard functions were calculated by the use of Poisson regression scheduled for bypass surgery between 1 Jan 1995 and 31 July 2005. The analyses were performed in two states: 1) in the period after triage until admission for surgery during which optimal medication was intended and 2) after surgery and up to 11 years (corresponding to 57,548 patient years). The probability of death was calculated by entering individual risk profile data into the two multivariable functions. There were several significant differences between the hazard functions in the two states. All variables reflecting angiographic severity of coronary lesions indicated lower risk of death after bypass surgery. The risk associated with left ventricular impairment was lower after surgery (beta coefficients − 0.0546 vs. − 0.0234, p <0.001). Only one variable, age, indicated higher risk after surgery (which is also seen in a general population over time). The reduction of risk was dependent on preoperative risk with a large reduction when preoperative risk was high and vice versa. When preoperative risk was low, however, the risk increased due to surgical mortality. Conclusions. The risk of death is lower after bypass surgery than before the operation in high risk patients. This is most likely explained by a prognostic gain from bypass surgery. The gain is largest in high-risk patients but small or absent in low risk patients.