Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair.

OBJECTIVE: To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS: Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS: No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS: Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.

The use of "LAST" operation in high risk patient.

BACKGROUND: The LAST operation, in spite of few drawbacks, represents a good option for single Left Anterior Descending (LAD) revascularization. This procedure does not allow multivessel revascularization, where hybrid procedure have been previous described. We report preliminary experience with the LAST operation performed in high risk patients. MATERIAL AND METHODS: From October 2004 to February 2005, 11 male high risk patients (mean age 74 +/- 8 years) underwent the LAST operation. Mean predicted death with EUROSCORE and Parsonnet score were 29% and 31% respectively. All patients had a proximal LAD lesion either not suitable for PTCA and multivessel coronary artery disease. The mean preoperative Ejection Fraction was 42 +/- 5% (27-55%). Four patients (36.4%) had previous surgical myocardial revascularization. An incision of about 6 cm was made in the appropriate intercostal space and the LIMA (Left Internal Mammary Artery) was harvested using a special costal retractor. After heparin administration the LIMA is distally divided to check the adequacy of the blood flow. Following the insertion of a temporary intracoronary shunt, the LIMA was LAD anastomosis was carried out with a continuous 8-0 polypropylene suture. RESULTS: No hospital or late mortality was observed. Uneventful conversion to midline sternotomy was necessary in one patient with low value of mammary flow. All patients were discharged within the first postoperative week. CONCLUSIONS: The use of the LAST operation enhances the role of minimally invasive surgery also in high risk patients who need coronary revascularization.

Systems of care for treatment of adolescent substance use disorders: background, principles and opportunities.

Adolescent substance abuse is a serious social problem facing the United States. Despite numerous recent advances in the clinical effectiveness of treatment approaches for this population, not enough attention has been paid to the adolescent treatment and service delivery infrastructures. The right services must be delivered through carefully organized and systematic community partnerships among agencies that serve the youth and families most in need. This article provides a working definition for the systems of care approach, reviews the movement's history within children's mental health services, addresses the feasibility of using the systems of care model for adolescent substance use disorders, and discusses principles and elements essential for successfully implementing a system of care for treatment of adolescent substance use disorders.