Direct oral anticoagulants in atrial fibrillation following cardiac surgery: a systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) have been increasingly used as anticoagulation therapy in the postoperative period. However, their effectiveness in post-cardiac surgical atrial fibrillation is yet to be determined. METHODS: We conducted a meta-analysis, searching three international databases from 1 January 2003 to 26 January 2022 for studies reporting on DOACs in at least 10 adult patients (>18 yr of age) with post-cardiac surgical atrial fibrillation. The primary outcomes were major neurological events and bleeding; secondary outcomes were mortality, hospital and ICU length of stay, cost, and other complications from therapy. We included studies of any design, including RCTs, cohort studies with and without propensity score matching methods, and single-armed case series. RESULTS: Twelve studies (8587 DOACs; 8315 warfarin) were included in this meta-analysis. The incidences of postoperative bleeding and major neurological events with DOACs were 7.3% (95% confidence interval [CI]: 3.4-14.7%) and 2.2% (95% CI: 0.9-4.9%), respectively. The incidence of major neurological events was lower in high-risk patients, including those with hypertension and higher CHA2DS2-VASc score, whereas patients with prior transient ischaemic attack or stroke had higher incidence of bleeding. Trial sequential analysis revealed that the cumulative Z-curve crossed the conventional boundary of benefit. Compared with warfarin, DOACs reduced the risk of bleeding (relative risk [RR] 0.74; 95% CI: 0.62-0.89; P=0.0011) and major neurological events (RR 0.63; 95% CI: 0.48-0.83; P=0.0012) but not mortality (RR 1.02; 95% CI: 0.77-1.35; P=0.090). CONCLUSIONS: DOACs reduced bleeding and major neurological events in patients with post-cardiac surgical atrial fibrillation, appearing safer than warfarin in this context. However, which specific DOAC provides the most effective anticoagulation in this patient population needs further investigation. CLINICAL TRIAL REGISTRATION: PROSPERO CRD42021282777.

Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections.

Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.

Minimally Invasive Coronary Artery Bypass Grafting in a Low-Risk Asian Cohort: A Propensity-Score Matched Study.

INTRODUCTION: Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new paradigm in coronary revascularization. This study aims to compare the outcomes of MICS CABG with those of conventional median sternotomy CABG (MS CABG) within a growing minimally invasive cardiac surgical program in Singapore. METHODS: Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2). RESULTS: Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups. CONCLUSION: MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.

Routine preoperative screening computed tomography of the thorax for cardiac surgery.

Introduction: This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods: All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results: A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy (P = 0.016) but not with postoperative stroke (P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax (P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy (P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion: The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.

Comparison of the safety and efficacy between minimally invasive cardiac surgery and median sternotomy in a low-risk mixed Asian population in Singapore.

Introduction: Minimally invasive cardiac surgery (MICS) has attracted increasing attention, with institutions increasingly adopting this approach over conventional median sternotomy (MS). This study aimed to describe the outcomes of minimally invasive cardiac surgery in our institution as the only centre with an established MICS programme in Singapore. Methods: Patients who had undergone cardiac procedures such as heart valve replacement or repair, coronary artery bypass grafting or atrial septal defect repair were included in the study. We analysed 4063 patients who had undergone MS and 390 patients who had undergone MICS between January 2009 and February 2020. Results: Over the years, the number of MICS procedures performed increased, along with an increase in MICS operations with two or more concomitant cardiac procedures and a decrease in postoperative length of stay. Compared with patients who underwent MS, those who underwent MICS had shorter length of postoperative hospital stay (P < 0.001). On multivariate analysis, patients who underwent MICS had lower rates of atrial fibrillation (P = 0.021), reoperation (P = 0.028) and prolonged ventilation (P < 0.001). However, the rates of other postoperative complications were comparable between patients who underwent MICS and those who underwent MS. Conclusion: In our institution, MICS is a safe, reproducible and efficacious technique that yields superior outcomes compared with conventional MS procedures, in some aspects. The results of this study provide further evidence and support towards adopting the minimally invasive approach to cardiac surgery in a carefully selected group of cardiac patients in Singapore.

Mid-term single-center outcomes of BioIntegral compared to Freestyle aortic conduit implantation.

BACKGROUND: Full aortic root replacement with biological conduit has limited options. This non-randomized cohort study aims to compare mid-term clinical and hemodynamic results of the BioIntegral (BI) composite biological versus the stentless Freestyle (FS) conduits in patients undergoing full aortic root replacement. METHODS: From February 2013 to July 2017, 265 patients underwent aortic root replacement at a single institution (202 BI, 65 FS). Preoperative, intraoperative and postoperative parameters, complications including stroke, myocardial infarction (MI), endocarditis and reoperation were studied. Hemodynamic performance of both conduits was analyzed by echocardiography. Target endpoints were 30-day mortality, two-year survival, two-year freedom from major adverse valve-related and cardiovascular events. RESULTS: Wider BI conduits were used (BI 27±2 vs. FS 25±2 mm, P<0.0001). The BI group had shorter cardiopulmonary bypass (BI 165±67 vs. FS 200±78 min, P<0.0001) and cross-clamp (BI 102±36 vs. FS 122±40 min, P=0.001) times. Thirty-day mortality was similar in both groups. There were fewer conduit-related reoperations in the BI group (BI 0% vs. FS 3%, P=0.012) but higher postoperative atrial fibrillation (BI 31% vs. FS 17%, P=0.025). No significant differences were observed for stroke (BI 5% vs. FS 10%, P=0.947), MI (BI 3% vs. FS 4%, P=0.583), or infective endocarditis (BI 0% vs. FS 2%, P=0.077). No significant hemodynamic differences were evident on follow-up echocardiography while an improved overall survival trend was seen in the BI group (P=0.062). CONCLUSIONS: FS and BI provide comparable clinical mid-term results and hemodynamic parameters. Simplified implantation technique providing shorter cardiopulmonary bypass and operation times are advantageous for BI.

Minimally Invasive Coronary Artery Bypass Grafting in a Low-Risk Asian Cohort: A Propensity-Score Matched Study

ABSTRACT Introduction: Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new paradigm in coronary revascularization. This study aims to compare the outcomes of MICS CABG with those of conventional median sternotomy CABG (MS CABG) within a growing minimally invasive cardiac surgical program in Singapore. Methods: Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2). Results: Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups. Conclusion: MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.

Video-assisted thoracoscopic surgery atrial clipping for atrial fibrillation.

The majority of thrombi that arise due to atrial fibrillation occur in the left atrial appendage. Eliminating this cul-de-sac within the left atrium reduces the risk of stroke in these patients. We present a unique case of left atrial appendage occlusion performed via video-assisted thoracoscopic surgery, using an Atriclip to occlude the left atrial appendage in a patient with atrial fibrillation in whom anticoagulation was contraindicated due to a history of recurrent upper gastrointestinal bleeding.