Luca Maschietto

Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting

Importance The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Objective To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone. Design, Setting, and Participants This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015. Exposures Before surgery, patients received ticagrelor with or without aspirin or aspirin alone. Main Outcomes and Measures Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates. Results Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group. Conclusions and Relevance In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

Glycated Hemoglobin and Risk of Sternal Wound Infection After Isolated Coronary Surgery

BACKGROUND Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG.Methods and Results:Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54±17 vs. 45±13 mmol/mol, P<0.0001). This difference was also observed in patients without a diagnosis of diabetes (P=0.027), in insulin-dependent diabetic (P=0.023) and non-insulin-dependent diabetic patients (P=0.034). In the overall series, HbA1c >70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47-10.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24-3.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38-5.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24-3.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17-4.69). CONCLUSIONS Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI.

Incidence and prognostic impact of bleeding and transfusion after coronary surgery in low-risk patients

Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low‐risk patients undergoing coronary artery bypass grafting (CABG).

Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Background The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors’ institution (1999‐September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)‐matched analysis was also performed. Results Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p = 0.66) and the PS‐matched series (0 vs. 4.3%; p = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re‐exploration) was increased both in the overall (p = 0.037) and the PS‐matched series of BITA patients (p = 0.092); duration of surgery was increased but not quite significantly (p = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS‐matched BITA patients, even though not quite significantly (p = 0.11 for both). Conclusion BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better.

Preoperative Intra-Aortic Counterpulsation in Cardiac Surgery: Insights From a Retrospective Series of 588 Consecutive High-Risk Patients

OBJECTIVE To support a rational use of preoperative intra-aortic balloon pump (IABP) in cardiac surgery. DESIGN Retrospective, observational study. SETTING Single university hospital. PARTICIPANTS The study included 588 (mean age 68.5 ± 9.6 yr) consecutive patients who received IABP before cardiac surgery from 1999 to 2016. INTERVENTIONS Coronary surgery was performed in 573 (97.4%) cases. IABP indications were prophylaxis (n = 147), unstable angina (n = 239), and rapid worsening of hemodynamics (n = 202). Baseline characteristics of patients were analyzed with multivariable methods. Comparison of outcomes postsurgery between 74 patients undergoing IABP because of left main coronary artery disease (LMCAD) (stenosis ≥ 50%) and a new series of 1,360 patients experiencing LMCAD but who did not receive an IABP using propensity-score matching. MEASUREMENTS AND MAIN RESULTS Throughout the study period, the rate of IABP use for prophylaxis and unstable angina increased (p = 0.0029) despite reduction in patient surgical risk (p = 0.0051). Early period of surgery (p = 0.032), rapid worsening of hemodynamics in the operating room (p = 0.0029), renal impairment (p < 0.0001), and ventilation before surgery (p = 0.0032) were predictors of in-hospital mortality. The cumulative rate of IABP-related complications was 6.8%. Current smoking (p = 0.025) and the use of a 9 Fr catheter (p = 0.0017) were predictors of IABP-related vascular complications. No difference was found regarding outcomes postsurgery for 43 pairs of IABP/non-IABP matched patients with LMCAD, even though preoperative IABP was associated with an increased use of bilateral internal thoracic artery grafting. CONCLUSIONS Preoperative use of IABP in cardiac surgery was shown in this study to be safe, even for high-risk patients. LMCAD is not by itself a sufficient indication for prophylactic IABP.