Coronary artery bypass grafting-related bleeding complications in patients treated with dual antiplatelet treatment.

OBJECTIVES: To evaluate the relationship between the timing of either ticagrelor or clopidogrel discontinuation and bleeding-related complications in patients undergoing isolated on-pump coronary artery bypass grafting (CABG). METHODS: Between January 2012 and December 2014, 705 consecutive patients underwent isolated on-pump CABG at our institution. Of these, 626 were eligible for this study. Surgery under acetylsalicylic acid (ASA) was performed in 404 patients (ASA group) and 222 patients underwent surgery under dual antiplatelet treatment (DAPT). Patients exposed to DAPT were stratified into the following groups: ticagrelor within 72 h prior to surgery (Group T ≤ 72, n = 63); ticagrelor within 72-120 h prior to surgery (Group T72-120, n = 21); clopidogrel within 120 h prior to surgery (Group C ≤ 120, n = 125); clopidogrel within 120-168 h prior to surgery (Group C120-168, n = 13). RESULTS: Transfusion requirements in Group T ≤ 72 (72.1 vs 41.3%, P < 0.001) and Group C ≤ 120 (71.2 vs 41.3%, P < 0.001) were significantly higher compared with the ASA group. Multivariable analysis, comparing Group C ≤ 120, C120-168, T ≤ 72 and T72-120 with the ASA group, revealed Group C ≤ 120 and Group T ≤ 72 as predictors of bleeding-related complications. No increased incidence of bleeding-related complications was seen when ticagrelor was discontinued >72 h or clopidogrel >120 h prior to surgery. CONCLUSIONS: Ticagrelor discontinuation >72 h and clopidogrel discontinuation >120 h prior to surgery were not associated with an increased risk of bleeding-related complications. Based on these findings, a period of ticagrelor discontinuation shorter than advised by current international guidelines might be justifiable.

Valve-sparing aortic root replacement†.

OBJECTIVES: To evaluate our results of valve-sparing aortic root replacement and associated (multiple) valve repair. METHODS: From September 2003 to September 2013, 97 patients had valve-sparing aortic root replacement procedures. Patient records and preoperative, postoperative and recent echocardiograms were reviewed. Median age was 40.3 (range: 13.4-68.6) years and 67 (69.1%) were male. Seven (7.2%) patients were younger than 18 years, the youngest being 13.4 years. Fifty-four (55.7%) had Marfan syndrome, 2 (2.1%) other fibrous tissue diseases, 15 (15.5%) bicuspid aortic valve and 3 (3.1%) had earlier Fallot repair. The reimplantation technique was used in all, with a straight vascular prosthesis in 11 (26-34 mm) and the Valsalva prosthesis in 86 (26-32 mm). Concomitant aortic valve repair was performed in 43 (44.3%), mitral valve repair in 10 (10.3%), tricuspid valve repair in 5 (5.2%) and aortic arch replacement in 3 (3.1%). RESULTS: Mean follow-up was 4.2 ± 2.4 years. Follow-up was complete in all. One 14-year old patient died 1.3 years post-surgery presumably of ventricular arrhythmia. One patient underwent reoperation for aneurysm of the proximal right coronary artery after 4.9 years and 4 patients required aortic valve replacement, 3 of which because of endocarditis after 0.1, 0.8 and 1.3 years and 1 because of cusp prolapse after 3.8 years. No thrombo-embolic complications occurred. Mortality, root reoperation and aortic regurgitation were absent in 88.0 ± 0.5% at 5-year follow-up. CONCLUSIONS: Results of valve-sparing root replacement are good, even in association with a high incidence of concomitant valve repair. Valve-sparing aortic root replacement can be performed at a very young age as long as an adult size prosthesis can be implanted.

Continuous Postoperative Pericardial Flushing: A Pilot Study on Safety, Feasibility, and Effect on Blood Loss.

BACKGROUND: Prolonged or excessive blood loss is a common complication after cardiac surgery. Blood remnants and clots, remaining in the pericardial space in spite of chest tube drainage, induce high fibrinolytic activity that may contribute to bleeding complications. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. In this pilot study, the safety and feasibility of CPPF were evaluated and the effect on blood loss and other related complications was investigated. METHODS: Between November 2011 and April 2012 twenty-one adult patients undergoing surgery for congenital heart disease (CHD) received CPPF from sternal closure up to 12 h postoperative. With an inflow Redivac drain that was inserted through one of the chest tube incision holes, an irrigation solution (NaCl 0.9% at 38 °C) was delivered to the pericardial cavity using a volume controlled flushing system. Safety aspects, feasibility issues and complications were registered. The mean actual blood loss in the CPPF group was compared to the mean of a retrospective group (n = 126). RESULTS: CPPF was successfully completed in 20 (95.2%) patients, and no method related complications were observed. Feasibility was good in this experimental setting. Patients receiving CPPF showed a 30% (P = 0.038) decrease in mean actual blood loss 12 h postoperatively. CONCLUSIONS: CPPF after cardiac surgery was found to be safe and feasible in this experimental setting. The clinically relevant effect on blood loss needs to be confirmed in a randomized clinical trial.

Reoperation for neoaortic root pathology after the arterial switch operation.

OBJECTIVES: To evaluate incidence and results of surgical intervention for neoaortic root pathology following arterial switch operation (ASO) for transposition of the great arteries (TGA). METHODS: Between April 1996 and August 2013, 12 patients underwent reoperation for neoaortic root dilatation (ARD) and/or neoaortic valve regurgitation (AR). Maximal aortic sinus and annulus diameter Z-scores were recorded. Original diagnoses were TGA/IVS (6), TGA/ventricular septal defect (VSD) (4) and Taussig-Bing anomaly (2) with ASO at a median age of 0.1 (range: 0-10.6) years. Age at ASO, VSD and complex TGA were reviewed as possible risk factors for reoperation. RESULTS: Twelve patients with tricuspid neoaortic valves underwent 15 root operations; indications were root dilatation (4) and root dilatation with AR (8). Median age was 18.0 (3.0-29.0) years at first reoperation. Median aortic root Z-score at reoperation was 6.33 (range: 3.84-12.15). Procedures were: Bentall procedure (6), aortic valve replacement (2), neoaortic valve plasty (1), supracoronary tube (1) and switch-back operation (2). Mean follow-up was 7.0 ± 5.7 years and complete. No mortality occurred. One patient had two reoperations for late endocarditis. Technical difficulties were encountered related to specific anatomy post-ASO concerning coronary anatomy, poor exposure and thin-walled aorta at the site of pulmonary artery bifurcation after Lecompte manoeuvre. Valve sparing surgery seemed not feasible due to specific anatomy of the neoaortic root and valve. No risk factors for reoperation could be identified. CONCLUSIONS: After ASO, surgery for neoaortic root pathology may become necessary when follow-up is long enough and regardless of primary diagnosis or other risk factors. Redo neoaortic surgery can be performed with low risk taking into account the specific technical difficulties.