Transcatheter Aortic Valve Implantation in Low-Risk Tricuspid or Bicuspid Aortic Stenosis: The NOTION-2 Trial.

BACKGROUND AND AIMS: Transcatheter aortic valve implantation (TAVI) has become the first choice to treat older patients with severe symptomatic aortic stenosis (AS). This study aimed to compare TAVI with surgery in low-risk patients ≤ 75 years of age, including both tricuspid and bicuspid AS. METHODS: The NOTION-2 trial enrolled and 1:1 randomized low-risk patients aged ≤ 75 years with severe symptomatic AS to TAVI or surgery. The primary endpoint was a composite of all-cause mortality, stroke or rehospitalization (related to the procedure, valve or heart failure) at 12 months. RESULTS: A total of 370 patients were enrolled with a mean age of 71.1 years and a median Society of Thoracic Surgeons risk score of 1.1%. A total of 100 patients had bicuspid AS. The 1-year incidence of the primary endpoint was 10.2% in the TAVI group and 7.1% in the surgery group (absolute risk difference 3.1%; 95% confidence interval [CI], -2.7% to 8.8%; hazard ratio (HR) 1.4, 95% CI: 0.7 to 2.9; p=0.3). Patients with TAVI, when compared to surgery, had lower risk of major bleeding and new-onset atrial fibrillation and higher risk of non-disabling stroke, permanent pacemaker implantation and moderate-or-greater paravalvular regurgitation. The risk of the primary composite endpoint was 8.7% and 8.3% in patients with tricuspid AS (HR 1.0, 95% CI: 0.5 to 2.3) and 14.3% and 3.9% in patients with bicuspid AS (HR 3.8, 95% CI: 0.8 to 18.5) treated with TAVI or surgery, respectively (P for interaction=0.1). CONCLUSIONS: Among low-risk patients aged ≤ 75 years with severe symptomatic AS, the rate of the composite of death, stroke, or rehospitalization at one year was similar between TAVI and surgery. TAVI outcomes in young bicuspid AS patients warrant caution and should be further investigated. (NOTION-2, ClinicalTrials.gov, NCT02825134).

Conservative treatment of type A aortic dissection: a case report with 5 years of follow-up.

Background: Acute aortic dissection causes major morbidities and mortalities. The treatment of choice for type A aortic dissection (TAAD) is emergent surgical intervention. However, surgery per se may be associated with significant risk, in part due to the general surgical challenges, and the inherent hemodynamic- and organ malperfusion effects. In particular, surgery correlates with marked perioperative mortality in octo- and nonagenarians and those with severe comorbidities. Conservative medical treatment represents an alternative approach to patients for whom surgery is deemed high-risk, but case literature in this field remains sparse. Case Description: We present a case of an 86-year-old female admitted with TAAD and deemed inoperable by the cardiothoracic surgical team due to excessive risks. The patient was treated conservatively with an extensive and aggressive antihypertensive regimen, leading to an uneventful recovery. Conclusions: Most cases of TAADs require emergent surgery. However, surgery is often contraindicated in comorbid and older patients due to excessive risks. The patient in this report is unique due to the long follow-up after conservative treatment and the close adherence to treatment protocol due to continuous therapeutic monitoring. It is important to consider factors for and against conservative therapeutic strategies, and, importantly, adherence to such should be carefully monitored to optimize patient outcomes.

Long-term survival, functional capacity and quality of life after refractory out-of-hospital cardiac arrest treated with mechanical circulatory support.

Introduction: Studies on long-term outcomes after refractory out-of-hospital cardiac arrest (OHCA) treated with mechanical circulatory support (MCS) are limited. This study aimed to evaluate long-term neurologically intact survival, functional capacity and quality of life after refractory OHCA treated with MCS. Methods: This was a follow-up study of survivors after refractory OHCA treated with MCS. Follow-up examinations comprised clinical assessment with transthoracic echocardiography and cardiopulmonary exercise test (CPX). Neurological and cognitive screening was evaluated with the Cerebral Performance Category (CPC) and Montreal Cognitive Assessment (MoCA test). A good neurological outcome was defined as CPC 1 or CPC 2. Health-related quality of life was measured by questionnaires (Short Form-36 (SF-36)). Results: A total of 101 patients with refractory OHCA were treated with MCS at Aarhus University Hospital between 2015 and 2019. The total low-flow time was median 105 min [IQR, 94-123] minutes. The hospital discharge rate was 27%. At a mean follow-up time of 4.8 years ± 1.6 (range 2.8-6.1 years), 21 patients remained alive of whom 15 consented to participate in the present study. Good neurological outcome with CPC 1-2 was found in 93% (14/15) patients. No severe cognitive function was discovered; mean MoCA score of 26.4 ± 3.1. Functional capacity examined by CPX showed acceptable VO2 max values (23.9 ± 6.3 mL/kg/min). Mean SF-36 scores revealed an overall high level of quality of life in long-term survivors. Conclusions: Long-term survival with a good neurological outcome with functional recovery was high in patients with refractory OHCA treated with MCS. These patients may expect a reasonable quality of life after discharge despite prolonged resuscitation.

Increasing obesity is associated with lower postoperative bleeding in coronary bypass patients.

OBJECTIVE: Despite inherent comorbidities, obese cardiac surgical patients paradoxically had shown lower morbidity and mortality, although the nature of this association is still unclear. Thus, the authors intended in this large registry-based study to investigate the impact of obesity on short- and long-term postoperative outcomes, focusing on bleeding and transfusion requirements. DESIGN: Retrospective registry study. SETTING: Three university hospitals. PARTICIPANTS: A cohort of 12,330 prospectively compiled data from coronary bypass grafting patients undergoing surgery between 2007 to 2020 were retrieved from the Western Denmark Heart Registry. INTERVENTIONS: The parameters were analyzed to assess the association between body mass index (BMI) and the selected outcome parameters. MEASUREMENTS AND MAIN RESULTS: The crude data showed a clear statistically significant association in postoperative drainage from 637 (418-1108) mL in underweight patients with BMI <18.5 kg/m2 to 427 (295-620) mL in severely obese patients with BMI ≥40 kg/m2 (p < 0.0001, Kruskal-Wallis). Further, 50.0% of patients with BMI <18.5 received an average of 451 mL/m2 in red blood cell transfusions, compared to 16.7% of patients with BMI >40 receiving 84 mL/m2. The obese groups were less often submitted to reexploration due to bleeding, and fewer received perioperative hemostatics, inotropes, and vasoconstrictors. The crude data showed increasing 30-day and 6-month mortality with lower BMI, whereas the one-year mortality showed a V-shaped pattern, but BMI had no independent impact on mortality in logistic regression analysis. CONCLUSION: Patients with high BMI may carry protection against postoperative bleeding after cardiac surgery, probably secondary to an inherent hypercoagulable state, whereas underweight patients carry a higher risk of bleeding and worse outcomes.

Fewer transfusions are still more-red blood cell transfusions affect long-term mortality in cardiac surgery.

OBJECTIVES: Previous studies indicated higher long-term mortality after the transfusion of allogeneic red blood cells (RBC); newer recommendations emphasize lower transfusion rates. The consequences of the transfusion of RBCs in cardiac surgery are unclear because later studies focused on transfusion triggers and short-term outcomes. Reports on long-term complications after cardiac surgery are few. MATERIAL AND METHODS: The mandatory Western Denmark Heart Registry was used to identify all adult cardiac operations performed in 4 centres from 2000 to 2019. Patients with multiple entries or previous cardiac operations, special/complex procedures, dying within 30 days and not eligible for follow-up were excluded. RESULTS: A total of 32,581 adult cardiac operations performed in 4 centres from 2000 to 2019 were included. The Kaplan-Meier survival plot for low-risk patients undergoing simple cardiac operations showed a significantly lower 15-year survival (0.384 vs 0.661) of patients who received perioperative RBC transfusions [odds ratio 2.43 (confidence level 2.23-2.66)]. The risk decreased with increasing comorbidity or age. No difference was found in high-risk patients. The adjusted risk ratio after an RBC transfusion, including age, sex, comorbidity and surgery, was 1.62 (1.48-1.77). CONCLUSIONS: Despite reduced transfusion rates, long-term follow-up on especially low-risk patients undergoing comparable cardiac operations still demonstrates substantially more deaths of patients receiving perioperative RBC transfusions. Even transfusion of 1-2 units is associated with increased long-term mortality.

Temperature effects on incidence of surgery for acute type A aortic dissection in the Nordics.

We aimed to investigate a hypothesised association between daily mean temperature and the risk of surgery for acute type A aortic dissection (ATAAD). For the period of 1 January 2005 until 31 December 2019, we collected daily data on mean temperatures and date of 2995 operations for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Using a two-stage time-series approach, we investigated the association between hot and cold temperatures relative to the optimal temperature and the rate of ATAAD repair in the selected cities. The relative risks (RRs) of cold temperatures (≤-5°C) and hot temperatures (≥21°C) compared to optimal temperature were 1.47 (95% CI: 0.72-2.99) and 1.43 (95% CI: 0.67-3.08), respectively. In line with previous studies, we observed increased risk at cold and hot temperatures. However, the observed associations were not statistically significant, thus only providing weak evidence of an association.

Impact of national holidays and weekends on incidence of acute type A aortic dissection repair.

Previous studies have demonstrated that environmental and temporal factors may affect the incidence of acute type A aortic dissection (ATAAD). Here, we aimed to investigate the hypothesis that national holidays and weekends influence the incidence of surgery for ATAAD. For the period 1st of January 2005 until 31st of December 2019, we investigated a hypothesised effect of (country-specific) national holidays and weekends on the frequency of 2995 surgical repairs for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Compared to other days, the number of ATAAD repairs were 29% (RR 0.71; 95% CI 0.54-0.94) lower on national holidays and 26% (RR 0.74; 95% CI 0.68-0.82) lower on weekends. As day of week patterns of symptom duration were assessed and the primary analyses were adjusted for period of year, our findings suggest that the reduced surgical incidence on national holidays and weekends does not seem to correspond to seasonal effects or surgery being delayed and performed on regular working days.

Once after a full moon: acute type A aortic dissection and lunar phases.

OBJECTIVES: Acute type A aortic dissection (ATAAD) is a rare but severe condition, routinely treated with emergent cardiac surgery. Many surgeons have the notion that patients with ATAAD tend to come in clusters, but no studies have examined these observations. This investigation was undertaken to study the potential association between the lunar cycle and the incidence of ATAAD. METHODS: We collected information on 2995 patients who underwent ATAAD surgery at centres from the Nordic Consortium for Acute Type A Aortic Dissection collaboration. We cross-referenced the time of surgery with lunar phase using a case-crossover design with 2 different definitions of full moon (>99% illumination and the 7-day full moon period). RESULTS: The period when the moon was illuminated the most (99% definition) did not show any significant increase in incidence for ATAAD surgery. However, when the full moon period was compared with all other moon phases, it yielded a relative risk of 1.08 [95% confidence interval (CI) 1.00-1.17, P = 0.057] and, compared to waxing moon, only the relative risk was 1.11 (95% CI 1.01-1.23, P = 0.027). The peak incidence came 4-6 days after the moon was fully illuminated. CONCLUSIONS: This study found an overrepresentation of surgery for ATAAD during the full moon phase. The explanation for this is not known, but we speculate that sleep deprivation during full moon leads to a temporary increase in blood pressure, which in turn could trigger rupture of the aortic wall. While this finding is interesting, it needs to be corroborated and the clinical implications are debateable.

Platelet function assessed by ROTEM®platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery.

Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM®platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM®platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM®platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.

Giant unruptured aneurysm of the left coronary sinus of Valsalva presenting as acute coronary syndrome: a case report.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. Unruptured aneurysms may be asymptomatic but can present as malignant arrhythmias, acute chest pain, and even sudden cardiac death. Both ruptured and unruptured SVAs may have fatal complications, thus prompt diagnosis and surgery is critical. CASE SUMMARY: We report a successful surgical repair of an unruptured aneurysm of the left sinus of Valsalva presenting as acute coronary syndrome. Coronary angiography (CAG) and cardiac multislice computed tomography (CT) revealed a large unruptured aneurysm of the left sinus of Valsalva. Surgical repair was performed by resection of the aneurysm, aortic valve replacement with composite graft, and coronary artery bypass. DISCUSSION: Aneurysm of the left sinus of Valsalva is an extremely rare condition. Correct diagnosis can be done by echocardiography, CAG, or CT. Non-ruptured aneurysms should be surgically repaired if they are associated with significant symptoms or if their size enlarge rapidly.

Aortic valve and left ventricular outflow tract calcium volume and distribution in transcatheter aortic valve replacement: Influence on the risk of significant paravalvular regurgitation.

OBJECTIVES: We sought to determine the impact of aortic root calcium on the risk of significant paravalvular regurgitation (sPAR) in transcatheter aortic valve replacement (TAVR). METHODS: In 302 consecutive patients from 3 centers, aortic root calcium was quantified volumetrically on pre-TAVR multidetector computed tomography (MDCT) in three regions: 1) the aortic valve region, 2) the overall left ventricular outflow tract (LVOT) and 3) the upper LVOT. Transcathether heart valve (THV) oversizing was calculated as (THV nominal area/MDCT annular area-1) × 100. The study endpoint sPAR was a composite of post-dilatation (PD) and PAR > mild. RESULTS: sPAR occurred in 15% (46/302) of patients. Upper LVOT calcium volume was more predictive of sPAR than overall LVOT calcium volume, with an area under the receiver operating curve (AUC) (95% confidence interval [CI]) of 0.80 (0.67-0.89) vs. 0.60 (0.51-0.70); p = 0.0001. The optimal cut-off calcium volume thresholds determined from receiver operating curves were 21 mm3 and 30 mm3 for upper LVOT and overall LVOT calcium, respectively. Upper LVOT calcium ≥ 21 mm3, but not overall LVOT calcium ≥ 30 mm3, independently predicted sPAR, odds ratio (95%CI): 9.5 (4.1-22.3) vs 1.6 (0.6-2.7). Upper LVOT calcium was more predictive of sPAR in patients with THV oversizing ≥ 13% compared to patients with THV oversizing <13%, AUC (95% CI): 0.83 (0.72-0.93) vs. 0.67 (0.51-0.74); p < 0.0001. CONCLUSIONS: Upper LVOT calcium predicts more-than-mild paravalvular regurgitation following TAVR or the need for postdilatation. Upper LVOT calcium is most predictive of paravalvular regurgitation in the event of THV oversizing ≥ 13%.

High-pressure balloon fracturing of small dysfunctional Mitroflow bioprostheses facilitates transcatheter aortic valve-in-valve implantation.

AIMS: Transcatheter valve-in-valve (VIV) implantation is usually discouraged in small surgical tissue valves. We report our first ten cases of fracturing small dysfunctional Mitroflow bioprostheses by high-pressure balloon dilatation to increase the internal diameter of the surgical valve before VIV (BF-VIV). METHODS AND RESULTS: BF-VIV was performed in 10 patients (mean age 84±4 years) with failing Mitroflow valves size 19 mm (n=3, threshold of fracture 15 atm) and 21 mm (n=7, threshold of fracture 13 atm). An Edwards SAPIEN 3 or XT 20 mm or 23 mm transcatheter valve was implanted inside the fractured Mitroflow bioprosthesis. The procedure improved aortic valve area (0.7±0.3 vs. 1.1±0.3 cm2, p=0.001), reduced peak aortic valve gradient (66±27 vs. 29±7 mmHg, p=0.002), resolved aortic regurgitation and improved patients' NYHA functional class (p=0.005). One patient had a minor stroke with complete resolution of symptoms and another patient required a pacemaker due to AV block. All patients were still alive at the end of follow-up (438±255 days). CONCLUSIONS: Initial experience with transcatheter BF-VIV suggests that this method is feasible and safe, and that it improves aortic valve haemodynamics and clinical functional capacity. BF-VIV is a promising alternative to repeat surgery in patients with small failing Mitroflow bioprostheses.

Fracturing mechanics before valve-in-valve therapy of small aortic bioprosthetic heart valves.

AIMS: Patients with degraded bioprosthetic heart valves (BHV) who are not candidates for valve replacement may benefit from transcatheter valve-in-valve (VIV) therapy. However, in smaller-sized surgical BHV the resultant orifice may become too narrow. To overcome this, the valve frame can be fractured by a high-pressure balloon prior to VIV. However, knowledge on fracture pressures and mechanics are prerequisites. The aim of this study was to identify the fracture pressures needed in BHV, and to describe the fracture mechanics. METHODS AND RESULTS: Commonly used BHV of small sizes were mounted on a high-pressure balloon situated in a biplane fluoroscopic system with a high-speed camera. The instant of fracture was captured along with the balloon pressure. The valves were inspected for material protrusion and later dissected for fracture zone investigation and description. The valves with a polymer frame fractured at a lower pressure (8-10 atm) than those with a metal stent (19-26 atm). None of the fractured valves had elements protruding. CONCLUSIONS: VIV procedures in small-sized BHV may be performed after prior fracture of the valve frame by high-pressure balloon dilatation. This study provides tentative guidelines for expected balloon sizes and pressures for valve fracturing.

Colloids in Cardiac Surgery-Friend or Foe?

OBJECTIVE: The right choice of fluid replacement still is a matter of debate. Recently, two large-scale studies on the use of hydroxyethyl starches (HES) in the intensive care setting have been published, which have caused a huge shift in the daily practice of volume therapy. These results have been applied to patients outside intensive care. The aim of this study was to evaluate the impact this change has had on the outcomes in a large population of cardiac surgery patients, with a focus on the type of colloid infusion. DESIGN: A prospective, registered, observational study, using propensity score matching. SETTING: Cohort study from 3 university hospitals using a common registry. PARTICIPANTS: The study comprised 17,742 patients who were referred for cardiac surgery from 2007 to 2014. INTERVENTIONS: Patients were divided in groups according to perioperative fluid replacement with either crystalloids or colloids. The colloid group was further divided into HES or human albumin (HA). Analyses were based on the following 3 subsections: HES versus crystalloids, HA versus crystalloids, and HES versus HA, with use of propensity score matching or direct matching of cases. Primary outcome parameters were 30-day and 6-month mortality, new postoperative renal replacement therapy, and new cardiac ischemic events. MEASUREMENTS AND MAIN RESULTS: The groups were fully comparable in individual analyses. The use of HES had no impact on new dialysis and 30-day mortality. A Cox proportional regression analysis showed that HES had no impact on 6-month mortality and new postoperative ischemic events. When comparing HA with crystalloid use, a significantly increased risk in crude analysis was demonstrated on all outcome parameters; and when comparing HA with HES, a significantly higher risk was observed in HA patients in mortality parameters and new postoperative, but after adjustment, only the risk of new postoperative dialysis persisted. CONCLUSION: This study underlined the difficulties in establishing hardcore outcome data, even in large cohort studies. The findings seemed to diminish the magnitude of risk when using HES in cardiac surgery patients and seriously questioned the choice of HA when a plasma expander is needed.

Rational and timely haemostatic interventions following cardiac surgery - coagulation factor concentrates or blood bank products.

BACKGROUND: Cardiac surgery may cause a serious coagulopathy leading to increased risk of bleeding and transfusion demands. Blood bank products are commonly first line haemostatic intervention, but has been associated with hazardous side effect. Coagulation factor concentrates may be a more efficient, predictable, and potentially a safer treatment, although prospective clinical trials are needed to further explore these hypotheses. This study investigated the haemostatic potential of ex vivo supplementation of coagulation factor concentrates versus blood bank products on blood samples drawn from patients undergoing cardiac surgery. METHODS: 30 adults were prospectively enrolled (mean age=63.9, females=27%). Ex vivo haemostatic interventions (monotherapy or combinations) were performed in whole blood taken immediately after surgery and two hours postoperatively. Fresh-frozen plasma, platelets, cryoprecipitate, fibrinogen concentrate, prothrombin complex concentrate (PCC), and recombinant FVIIa (rFVIIa) were investigated. The haemostatic effect was evaluated using whole blood thromboelastometry parameters, as well as by thrombin generation. RESULTS: Immediately after surgery the compromised maximum clot firmness was corrected by monotherapy with fibrinogen or platelets or combination therapy with fibrinogen. At two hours postoperatively the coagulation profile was further deranged as illustrated by a prolonged clotting time, a reduced maximum velocity and further diminished maximum clot firmness. The thrombin lagtime was progressively prolonged and both peak thrombin and endogenous thrombin potential were compromised. No monotherapy effectively corrected all haemostatic abnormalities. The most effective combinations were: fibrinogen+rFVIIa or fibrinogen+PCC. Blood bank products were not as effective in the correction of the coagulopathy. CONCLUSION: Coagulation factor concentrates appear to provide a more optimal haemostasis profile following cardiac surgery compared to blood bank products.

Temporal changes in clot lysis and clot stability following tranexamic acid in cardiac surgery.

: Cardiac surgery induces a multifactorial coagulopathy. Regular use of tranexamic acid (TXA) is becoming standard of care. Clinical challenges include selecting optimal dosing regimen and balancing the benefit versus risk of additional dosing with antifibrinolytics. The objective was to evaluate the effect of TXA by assessing kinetic properties of plasma clot formation, clot stability, and clot fibrinolysis. The study was a prospective case follow-up of 28 patients undergoing cardiac surgery (mean age 63.9 years, 29% women). Blood samples were analysed at seven time points during the first 48 h after surgery. All patients were treated with TXA, 2 g at start surgery, 1 g during extra corporeal circulation, and 1 g after reversal of heparin. An automated clot lysis assay using tissue factor and tissue plasminogen activator (tPA) was performed to evaluate clot formation, stability, and fibrinolysis. TXA protects against facilitated fibrinolysis and induces up to 13-fold increase in clot stability. All patients showed complete resistance to tPA-induced fibrinolysis during the first 6 h after cardiac surgery declining to 33% of patients at 48 h. Impaired renal function was associated with prolonged resistance to tPA-induced fibrinolysis. Despite inhibition of fibrinolysis with TXA, the overall clot stability declines and the kinetic properties of clot formation were impaired after cardiac surgery. TXA induces a multifold increase in clot resistance to fibrinolysis but does not affect clot formation or clot stability. Monitoring the level of resistance to fibrinolysis may prevent overdosing in particular in patients with impaired renal function.

The association between platelet transfusion and adverse outcomes after coronary artery bypass surgery.

OBJECTIVES: Previous research suggests that platelet transfusion is associated with adverse events after coronary artery bypass grafting (CABG). The aim of the current analysis was to verify this hypothesis. METHODS: Data from 6745 consecutive patients undergoing CABG from 2006 through 2012 were collected. Patients receiving platelet transfusions intraoperatively or postoperatively in the intensive care unit were compared with control patients. To adjust for possible confounders, propensity score matching and conditional regression analyses were performed. Short-term outcomes were 30-day mortality, in-hospital myocardial infarction and stroke. Mid-term outcomes were 6-month mortality, and need for coronary angiography or repeat coronary revascularization within 6 months after surgery. Data were retrieved from the Western Denmark Heart Registry. RESULTS: Using propensity scores, 982 patients exposed to platelets were matched with 982 control patients. Platelet transfusion was associated with a higher rate of postoperative coronary angiography (adjusted odds ratio 2.34, 95% confidence interval 1.15-4.76). There was no significant association between platelet transfusion and postoperative mortality, myocardial infarction, stroke and need for repeat coronary revascularization. CONCLUSIONS: Platelet transfusion at the time of CABG is not associated with increased postoperative mortality, in-hospital myocardial infarction, stroke or need for repeat coronary revascularization.

Transcatheter mitral valve implantation via transapical approach: an early experience.

OBJECTIVES: As many as 50% of patients with severe symptomatic mitral valve regurgitation are denied surgical valve replacement or repair due to high operative risk. We describe an early series of cases of transcatheter implantation with a CardiAQ™ mitral valve via a transapical approach. METHODS: Three consecutive patients with an Society of Thoracic Surgeons (STS) mortality score of >22% were selected for transcatheter mitral valve implantation (TMVI) on compassionate grounds. All patients were elderly, had severe mitral regurgitation (MR), were in Class IV heart failure and deemed unsuitable for the MitraClip. Two of the patients had functional MR in the setting of ischaemic cardiomyopathy with left ventricular ejection fraction (LVEF) <40%, deemed while the remaining patient had chordal rupture with extensive anterior leaflet flail (preserved LVEF). Comorbidities included previous coronary artery bypass surgery (n = 2), severe pulmonary hypertension (n = 1) and moderate to severe chronic renal failure (n = 3). A CardiAQ mitral valve was implanted using fluoroscopy and transoesophageal (TEE) guidance via a standard transapical approach. RESULTS: Accurate prosthesis positioning and deployment with immediate elimination of the MR was achieved in all 3 cases. Two patients made full clinical recovery and were discharged home. Post-procedural TEE performed on Days 1, 30 and 60 days showed good valve function, stable valve position and minimal LVOT gradient. One patient expired on the postoperative day 9 due to pneumonia. CONCLUSIONS: TMVI using the CardiAQ™ device via a transapical approach is feasible and effective.

Abscess Formation after Septic Arthritis in the Sternoclavicular Joint of Two Healthy Men.

Abscess formation after septic arthritis in the sternoclavicular joint is a rare phenomenon in healthy people without immune suppression, intravenous drug abuse, or diabetes. Here we report two cases with formation of abscess in two middle-aged men, with no relevant comorbidities and no obvious sites of infection. The abscesses were both treated surgically with debridement followed by negative pressure wound therapy and antibiotics. The cases differ in diagnostic procedures and delay of diagnosis and broach the issues of handling a rare disease.