The impact of ticagrelor therapy on CABG-related bleeding in patients with STEMI managed with pPCI and following on-pump CABG.

Patients on double antiplatelet treatment who need early in-hospital coronary artery bypass grafting (CABG) are at high risk of major bleeding. In this study, we aimed to investigate the impact of ticagrelor preloading on CABG related bleeding in patients with ST-segment elevation myocardial infarction (STEMI) initially managed with primary percutaneous coronary intervention (pPCI). Patients with the diagnosis of STEMI who were managed with pPCI and underwent subsequent early (4-7 days following pPCI) or delayed (> 7 days following pPCI) on-pump CABG surgery were included. All study patients were preloaded with ticagrelor 180 mg prior to pPCI procedure. Patients' demographics, clinical variables, and short-term cardiovascular outcomes were recorded. This is a retrospective study which included 98 patients. Fifty-four (54%) patients underwent early and 44 (45%) patients underwent delayed CABG surgery. CABG-related bleeding occurred in 22 (22.4%) patients. There was no significant difference with respect to total ticagrelor dose and timing of the surgery between patients with or without CABG-related bleeding (p: 0.165 and p: 0.142). Multivariate analyses demonstrated that only preoperative hemoglobin level < 10.9 and use of mechanical cardiac support devices were independent predictors of CABG-related bleeding [OR: 3719, p: 0.009 and OR: 11,698, p: 0.004, respectively].There were three deaths within the 30 days of surgery, all occurring in patients with CABG-related bleeding. However, CABG-related bleeding was not associated with long-term cardiovascular events during the follow-up. Our results indicated that discontinuation of ticagrelor therapy 3 days prior to surgery is sufficient to avoid CABG-related bleeding. Moreover, early CABG following STEMI does not increase the risk of long-term cardiovascular events.

Decreasing time between first diagnosis of paroxysmal atrial fibrillation and cryoballoon ablation positively affects long-term consequences.

BACKGROUND: Patients with atrial fibrillation (AF) usually experience a worsening of their AF burden over time. We aimed to investigate timing of pulmonary vein isolation (PVI) by cryoballoon (CB-2) after the first clinical diagnosis of AF on ablation-related outcomes. METHODS: A total of 132 consecutive patients with paroxysmal AF undergoing PVI by CB-2 were included in the study. The patients were retrospectively sorted into two groups to evaluate differences in AF recurrence risk associated with early ablation (n = 89), defined as within 365 days of first AF diagnosis, and late ablation (n = 365), defined as > 365 days after first AF diagnosis. AF-free survival during follow-up was compared between groups. RESULTS: Although mean procedure times were comparable between groups, mean fluoroscopy times were lower in the early ablation group. For the whole study group, median (interquartile range) time from AF diagnosis to first ablation was 4.0 (2.0-11.3) months [3.0 (1.0-4.0) vs 14.0 (12.0-22.5) months in the early and late ablation groups, respectively]. Median follow-up for the whole population was 12.0 (12.0-18.0) months, and after the blanking period, 14 (10.6%) patients had arrhythmia recurrence (2 in the early and 12 in the late ablation groups). In the univariable Cox regression analysis and propensity score adjusted penalized Cox regression analysis, there was a significant association between delay in ablation time and AF recurrence (unadjusted hazard ratio = 7.74, 95% CI 2.26-40.1, p < 0.001, adjusted hazard ratio = 7.50, 95% CI 2.23-38.6, p < 0.001). CONCLUSION: Delays in treatment with CB-2 ablation may negatively affect AF-free survival rates among patients with paroxysmal AF.

Catheter Ablation for Atrial Fibrillation in Patients ≤30 Years of Age.

Pulmonary vein (PV) automaticity is an established trigger for paroxysmal atrial fibrillation (PAF), making PV isolation (PVI) the cornerstone of catheter ablation. However, data on triggers for atrial fibrillation (AF) and catheter ablation strategy in very young patients aged <30 years are sparse. A total of 51 young patients (mean age 24.0 ± 4.2 years, 78.4% men) with drug-refractory PAF underwent electrophysiology (EP) study and ablation at 5 EP centers. None of the patients had structural heart disease or family history of AF. EP study induced supraventricular tachycardia (SVT) in 12 patients (n = 12, 23.5%): concealed accessory pathway mediated orthodromic atrioventricular reentrant tachycardia in 3 patients, typical atrioventricular nodal reentrant tachycardia in 6 patients, left superior PV tachycardia in 1 patient, left atrial appendage tachycardia in 1 patient, and typical atrial flutter in 1 patient. In patients with induced SVTs, SVT ablation without PVI was performed as an index procedure, except for the patient with atrial flutter who received cavotricuspid isthmus ablation in addition to PVI. Remaining patients underwent radiofrequency (n = 15, 29.4%) or second-generation cryoballoon-based PVI (n = 24, 47%). There were no major complications related to ablation procedures. Follow-up was based on outpatient visits including 24-hour Holter-electrocardiogram at 3, 6, and 12 months after ablation, or additional Holter-electrocardiogram was ordered in case of symptoms suggesting recurrence. Recurrence was defined as any atrial tachyarrhythmia (ATA) episode >30 seconds after a 3-month blanking period. A total of 2 patients with atrioventricular nodal reentrant tachycardia, 1 with left atrial appendage tachycardia, experienced AF recurrence within the first 3 months and received PVI. After the 3-month blanking period, during a median follow-up of 17.0 ± 10.1 months, 44 of 51 patients (86.2%) were free of ATA recurrence. In the PVI group, 33 of 39 patients (84.6%) experienced no ATA recurrence. In conclusion, SVT substrate is identified in around a quarter of young adult patients with history of AF, and targeted ablation without PVI may be sufficient in the majority of these patients. PVI is needed in the majority and is safe and effective in this population.