R. Cartier

The benefits of cognitive training after a coronary artery bypass graft surgery

Cognitive deficits are frequent after coronary artery bypass graft surgery (CABG) in the elderly population. In fact, memory and attention deficits can persist several months after the surgery. Recent studies with healthy older adults have shown that memory and attention can be improved through cognitive training programs. The present study examined whether memory training (method of loci and story generation) and attentional training (dual-task computerized training) could improve cognitive functions in patients aged 65xa0years and older who underwent CABG surgery. Participants (nxa0=xa051) were assigned to one of three groups: (1) control group (tested at 1, 3 and 6xa0months after the surgery), (2) attention training followed by memory training, (3) memory training followed by attention training (groups 2 and 3: tested at 1, 2, 3 and 6xa0months after the surgery). The trainings took place between the 6th and 10th week following the surgery. The three groups were compared before and after each training program using attention and memory tests and neuropsychological tests. The results showed that attention and memory trainings lead to significant improvement in the cognitive domain that was trained. It thus seems that cognitive training can be a promising tool to enhance cognitive functions after a CABG surgery.

2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy

Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.

Atypical presentation of an anomalous origin of the right coronary artery with severe compression between the great vessels

Anomalous aortic origin of the right coronary artery is a rare coronary anomaly which, in a minority of cases, can cause clinical manifestations such as ischemic chest pain or arrhythmic syncope. We describe a case of anomalous aortic origin of the right coronary artery characterized by signs of left heart failure associated with ventricular tachycardia.

Characterization of hsp27 kinases activated by elevated aortic pressure in heart

Chronic hemodynamic overload results in left ventricular hypertrophy, fibroblast proliferation, and interstitial fibrosis. The small heat shock protein hsp27 has been shown to be cardioprotective and this requires a phosphorylatable form of this protein. To further understand the regulation of hsp27 in heart in response to stress, we investigated the ability of elevated aortic pressure to activate hsp27-kinase activities. Isolated hearts were subjected to retrograde perfusion and then snap frozen. Hsp27-kinase activity was measured in vitro as hsp27 phosphorylation. Immune complex assays revealed that MK2 activity was low in non-perfused hearts and increased following crystalline perfusion at 60 or 120xa0mmHg. Hsp27-kinase activities were further studied following ion-exchange chromatography. Anion exchange chromatography on Mono Q revealed 2 peaks (b and c) of hsp27-kinase activity. A third peak a was detected upon chromatography of the Mono Q flow-through fractions on the cation exchange resin, Mono S. The hsp27-kinase activity underlying peaks a and c increased as perfusion pressure was increased from 40 to 120xa0mmHg. In contrast, peak b increased over pressures 60–100xa0mmHg but was decreased at 120xa0mmHg. Peaks a, b, and c contained MK2 immunoreactivity, whereas MK3 and MK5 immunoreactivity was detected in peak a. p38 MAPK and phospho-p38 MAPK were also detected in peaks b and c but absent from peak a. Hsp27-kinase activity in peaks b and c (120xa0mmHg) eluted from a Superose 12 gel filtration column with an apparent molecular mass of 50xa0kDa. Hence, peaks b and c were not a result of MK2 forming complexes. In-gel hsp27-kinase assays revealed a single 49-kDa renaturable hsp27-kinase activity in peaks b and c at 60xa0mmHg, whereas several hsp27-kinases (p43, p49, p54, p66) were detected in peaks b and c from hearts perfused at 120xa0mmHg. Thus, multiple hsp27-kinases were activated in response to elevated aortic pressure in isolated, perfused rat hearts and hence may be implicated in regulating the cardioprotective effects of hsp27 and thus may represent targets for cardioprotective therapy.

Surgery Versus Transcatheter Interventions for Significant Paravalvular Prosthetic Leaks

OBJECTIVESnThis study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction onxa0long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy.nnnBACKGROUNDnPVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality.nnnMETHODSnFrom 1994 to 2014, 231 patients underwent SC (nxa0= 151) or TR (nxa0= 80) PVL correction. Propensity matchingxa0and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival inxa0a matched general population and to matched patients undergoing their first surgical valve replacement.nnnRESULTSnOver a median follow-up of 3.5 years, SC was associated with an important reduction in all-causexa0deathxa0orxa0hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18xa0toxa00.44; pxa0<xa00.001). There was a trend towards reduced all-cause death following SC versusxa0TRxa0(hazardxa0ratio:xa00.61; 95%xa0confidence interval: 0.37 to 1.02; pxa0= 0.06). Neither intervention normalizedxa0survivalxa0whenxa0compared with axa0general population or patients undergoing their first surgical valvexa0replacement.nnnCONCLUSIONSnIn patients with significant prosthetic PVL, surgery is associated with better long-term outcomesxa0compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across thexa0world.

614 Coronary Artery Bypass Grafting in octogenarians: Results over the course of three 5-year periods

BACKGROUND: The incidence of CABG in the octogenarian population is rising, making it essential to explore ways to minimize morbidity and mortality in this population with inherent increased surgical risk. The aim of this study was to compare outcomes in octogenarians undergoing either conventional CABG (CCAB) with cardiopulmonary bypass (CPB) or offpump CABG (OPCAB) in three consecutive five-year cohorts METHODS: A retrospective chart review included all octogenarians who underwent isolated CABG between 2000-2004 (n 177), and 2005-2009 (n 231) in our institution. Comparison of these cohorts was performed and findings were then compared to the previously published 1995-1999 cohort (n 125). RESULTS: OPCAB was performed in 49.6% of patients in the 1995-1999 cohort, 49.2% in the 2000-2004, and only 20.8% in the 2005-2009 cohort. In the earlier cohorts no surgeon performed more than 30% of cases in either group, however, a single surgeon dedicated to the technique performed 70% of OPCAB surgeries in the recent cohort. Mortality was similar for OPCAB and CCAB in 2000-2004 (5.9% vs 5%, P 0.96) and 2005-2009 (6.3% vs 8.7%, P 0.77). This was markedly different from the 1995-1999 cohort’s results of 4.8% vs 15.9% (P 0.04). Stroke rates were also not significantly different between operative strategies in the 2 recent cohorts (2000-2004 1.2% vs 0%; 2005-2009 2.1% vs 3.2%), while CCAB was associated with a significantly increased stroke risk in the early cohort (6.3% vs 0%, P 0.04). Degree of aortic atherosclerosis was not identified in the early group because transesophageal echocardiography was not yet routine. Severe aortic atherosclerosis was significantly higher in the OPCAB group of the 2000-2004 cohort (53% vs 21%, P 0.01), while there was no difference between groups in the recent cohort. For the 2005-2009 cohort, when patients operated by the dedicated OPCAB surgeon were excluded, incidence of severe aortic atherosclerosis was higher with OPCAB (64% vs 31%, P 0.001). CONCLUSION: These results support the conclusion that CABG surgery in an octogenarian population can be performed safely and with similar mortality and stroke rates with or without CPB when patients are appropriately selected. OPCAB may be especially beneficial in the context of severe aortic atherosclerotic disease, and should be considered even by surgeons who do not routinely perform off-pump surgery. Improved outcome compared to the earliest cohort may be due to better screening for aortic atherosclerotic disease and improved perioperative care. 615 INHALED MILRINONE ADMINISTRATION IN CARDIAC SURGERY: SIMPLE JET OR ULTRASONIC NEBULISATION?