Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial.

AIM: To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS: We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. RESULTS: We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. CONCLUSION: The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.

Priorities in coronary artery bypass grafting: Is midterm survival more dependent on completeness of revascularization or multiple arterial grafts?

OBJECTIVE: Both completeness of revascularization and multiple arterial grafts (multiple arterial coronary artery bypass grafting) have been associated with increased midterm survival after coronary artery bypass grafting. The purpose of this study was to evaluate the relative impact of completeness of revascularization and multiple arterial coronary artery bypass grafting on midterm survival after coronary artery bypass grafting. METHODS: A retrospective review of 17,411 isolated, primary coronary artery bypass grafting operations from January 2002 to June 2016 at a US academic institution was performed. Patients were divided into groups based on complete or incomplete revascularization and number of arterial grafts. Inverse probability of treatment weighting based on the generalized propensity score was performed to minimize imbalance in preoperative characteristics. Between-group differences in outcomes were assessed using multivariable logistic and Cox regression analyses, incorporating the propensity score weights. RESULTS: Patients undergoing multiple arterial coronary artery bypass grafting in this study were younger, had fewer comorbid conditions, and had lower incidence of left main stenosis compared with patients undergoing single-arterial coronary artery bypass grafting. Short-term perioperative outcomes were similar between groups once propensity score weighting was used to minimize between-group differences in preoperative variables. Median follow-up in the entire population was 630 days, but was 1366 days in the cohort with data available from the Social Security Death Index. Multiple arterial coronary artery bypass grafting was protective for midterm survival compared with single arterial coronary artery bypass grafting, regardless of complete or incomplete revascularization or strategy (multiple arterial complete revascularization vs single-arterial complete revascularization: hazard ratio, 0.82; 95% confidence interval, 0.69-0.97; P = .02; multiple arterial incomplete revascularization vs single-arterial incomplete revascularization: hazard ratio, 0.70; 95% confidence interval, 0.53-0.90; P = .007). CONCLUSIONS: After controlling for preoperative comorbidities, multiple arterial coronary artery bypass grafting provides a modest midterm survival benefit over single-arterial coronary artery bypass grafting irrespective of completeness of revascularization, suggesting that when forced to choose, surgeons may elect to pursue multiple arterial conduits.

The Racial Paradox in Multiarterial Conduit Utilization for Coronary Artery Bypass Grafting.

BACKGROUND: It has been established that outcomes for black patients undergoing coronary artery bypass graft surgery (CABG) are inferior to those of their white counterparts. The purpose of this study was to determine (1) whether rates of multiarterial grafting are different among black patients and white patients, and (2) whether racial differences exist in postoperative outcomes after accounting for grafting strategy. METHODS: A retrospective review of black patients (n = 2,810) and white patients (n = 13,569) who underwent isolated, primary CABG from January 2002 to June 2014 at a US academic institution was performed. A modified predicted risk of mortality (M-PROM) score was calculated for each patient using all The Society of Thoracic Surgeons variables for CABG excluding race. Multivariable linear, logistic, and Cox regression analyses were used to assess between-group differences, adjusted for M-PROM. RESULTS: Overall, 16,379 patients underwent CABG, and 2,441 (14.9%) received more than one arterial graft. When adjusted for M-PROM, the odds of blacks undergoing multiarterial CABG were 10% greater than for whites (p = 0.05). Blacks had worse inhospital outcomes, including higher odds of stroke (odds ratio 2.41, 95% confidence interval [CI]: 1.80 to 3.25) and prolonged intubation (odds ratio 2.01, 95% CI: 1.77 to 2.28). The increase in postoperative complications did not translate to a difference in inhospital mortality (p = 0.10) between racial cohorts. Moreover, among patients who underwent multiarterial grafting strategies, blacks had a hazard of mortality that was 34% higher (95% CI: 22% to 51%)) than that of their white counterparts. Among black patients, those who underwent multiarterial grafting strategies showed better long-term survival than those undergoing single grafting strategies (hazard ratio 0.86, 95% CI: 0.78 to 0.96). CONCLUSIONS: Despite similar rates of arterial grafting for black patients and white patients in this large single-center cohort, black patients continued to have significantly worse late survival when compared with white patients. Continued evaluation as to the causes of this disparity is warranted.

The Expanding Role of Endoscopic Robotics in Mitral Valve Surgery: 1,257 Consecutive Procedures.

BACKGROUND: The role of robotic instruments in mitral valve (MV) surgery continues to evolve. The purpose of this study was to assess the safety, efficacy, and scope of MV surgery using a lateral endoscopic approach with robotics (LEAR) technique. METHODS: From 2006 to 2013, a dedicated LEAR team performed 1,257 consecutive isolated MV procedures with or without tricuspid valve repair or atrial ablation. The procedures were performed robotically through five right-side chest ports with femoral artery or ascending aortic perfusion and balloon occlusion. Operative videos and data were recorded on all procedures and reviewed retrospectively. RESULTS: The mean age of all patients was 59.3 ± 20.5 years, and 8.4% (n = 105) had previous cardiac surgery. The MV repair was performed in 1,167 patients (93%). The MV replacement was performed in 88 patients (7%), and paravalvular leak repair in 2 patients. Concomitant atrial ablation was performed in 226 patients (18%), and tricuspid valve repair in 138 patients (11%). Operative mortality occurred in 11 patients (0.9%) and stroke in 9 patients (0.7%). Predischarge echocardiograms demonstrated mild or less mitral regurgitation in 98.3% of MV repair patients. At mean follow-up of 50 ± 26 months, 44 patients (3.8%) required MV reoperation. Application of the LEAR technique to all institutional isolated MV procedures increased from 46% in the first year to more than 90% in the last 3 years. CONCLUSIONS: Mitral valve repair or replacement, including concomitant procedures, can be performed safely and effectively using the LEAR technique. With a dedicated robotic team, the vast majority of patients with MV disorders, either isolated or with concomitant problems, can be treated using the LEAR technique.

Prospective randomized study of a protein-based tissue adhesive used as a hemostatic and structural adjunct in cardiac and vascular anastomotic repair procedures.

BACKGROUND: The purpose of this study was to determine whether adjunctive use of the bovine serum albumin and glutaraldehyde tissue adhesive BioGlue (BioGlue Surgical Adhesive; CryoLife, Inc) could reduce the rate of anastomotic bleeding in patients undergoing cardiac and vascular repair procedures when compared with a standard repair control. This was a prospective multicenter, randomized, controlled clinical trial conducted in accordance with the IRB at each participating institution. STUDY DESIGN: A total of 151 patients consented to participation and were randomly assigned to standard repair plus BioGlue (n = 76) or standard repair alone (n = 75). These two groups were statistically homogeneous for age, gender, race, procedure, and number of anastomoses. Patients underwent cardiac procedures (n = 49), aortic procedures (n = 105), or peripheral vascular procedures (n = 48). RESULTS: Anastomotic bleeding was significantly reduced in the BioGlue group (18.8% of anastomoses) compared with the control group (42.9% of anastomoses, p < 0.001). Pledget use was reduced in the BioGlue group (26.2%) compared with the control group (35.9%, p = 0.047). Days in the ICU and total days in the hospital were slightly higher in the control group. Adverse event profiles were equivalent between the two groups except for occurrence of neurological defects, which were threefold less in the BioGlue group (p = 0.009). CONCLUSIONS: This study demonstrates that using BioGlue as an adjunct to standard repair methods is safe and significantly reduces the occurrence of intraoperative anastomotic site bleeding in cardiac and vascular repair patients. Using BioGlue along suture lines reinforces anastomoses, thus minimizing pledget use.