Dual-Antiplatelet Therapy After Coronary Artery Bypass Grafting: A Survey of UK Cardiac Surgeons.

OBJECTIVE: Antiplatelet therapy after coronary artery bypass grafting (CABG) is important in postoperative medical management. Although cardiac surgeons are well-versed in the guidelines regarding discontinuation of dual-antiplatelet therapy (DAPT; aspirin and a P2Y12 antagonist) before CABG to minimize bleeding risk, there is considerable variability in DAPT dosing after CABG. The objective of this study was to explore the current trends in DAPT after CABG in the UK to improve understanding of the existing practice. DESIGN: This study used an online survey with 9 questions about the use of DAPT after CABG. An invitation to participate was sent to all adult cardiac surgeons currently in practice in the UK and the Republic of Ireland. SETTING: The study was conducted in the UK and the Republic of Ireland. PARTICIPANTS: Participants in this study were adult cardiac surgeons currently in practice in the UK and the Republic of Ireland. INTERVENTIONS: There were no interventions in this study. MEASUREMENTS AND MAIN RESULTS: Responses were received from across the UK (85.4% UK; 4% each from Scotland and Northern Ireland, 1.3% from Wales) and 5.3% from the Republic of Ireland. Fifty-seven percent of the respondents performed between 50 and 100 CABGs per year. Ninety-one percent of the respondents prescribe DAPT postoperatively, but the choice of which patients receive it varied. Most responding surgeons used DAPT for selective patient cohorts, such as those with acute coronary syndrome (51%), diffuse coronary artery disease (42%), perioperative myocardial infarction (36%), coronary endarterectomy (31%), or when bypassing a stented coronary artery (23%). Thirty-eight percent of the respondents began all their patients with CABGs on DAPT. The most preferred P2Y12 antagonist was clopidogrel, used by 75% of respondents and introduced on day 1 after surgical revascularization (71%). The routine duration for DAPT is 12 months, which 78% of the respondents preferred. The main reason for not starting DAPT in those surveyed was the bleeding risk associated with DAPT (72%). CONCLUSIONS: The survey uncovered variation in the use of DAPT after CABG. However, DAPT remains the preferred strategy after CABG in the UK. The study highlighted the need to develop standardized protocols for DAPT after CABG.

Antiplatelet Resistance in Patients Who Underwent Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis.

Antiplatelet therapy (APT) with aspirin and a P2Y12 inhibitor is commonly given to patients who underwent coronary artery bypass grafting (CABG) to reduce thrombotic events. APT resistance, the inadequate antiplatelet effect of these drugs, is a growing concern. This review aimed to assess APT resistance prevalence in patients who underwent CABG and its impact on clinical outcomes. We conducted a comprehensive search for relevant studies published to date. The included studies measured platelet function through laboratory assays and reported on clinical outcomes in patients who underwent CABG. The primary outcomes were major adverse cardiovascular events (MACEs) and mortality, whereas the secondary outcomes included acute coronary syndrome (ACS), stroke, and thromboembolic events. The meta-analysis used random-effects models, with heterogeneity assessed using the I2 statistic. The initial search identified 45 studies, with 11 meeting the inclusion criteria, involving 3,122 patients. The overall prevalence of APT resistance in patients who underwent CABG was 39%. Patients with APT resistance had significantly higher risks of MACEs and death (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.06 to 2.83, p = 0.03) and postoperative myocardial infarction (OR 2.25, 95% CI 1.13 to 4.48, p = 0.02) than those without resistance. However, no significant association was found between APT resistance and stroke (OR 2.25, 95% CI 0.80 to 6.35, p = 0.12) or other thromboembolic events (OR 1.72, 95% CI 0.72 to 4.08, p = 0.22). In conclusion, APT resistance is prevalent in a significant proportion of patients who underwent CABG, increasing the risk of MACEs and postoperative myocardial infarction. These findings emphasize the need for further research to develop tailored antiplatelet strategies in this patient population.

Use of Preoperative Natriuretic Peptide in Predicting Mortality After Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis.

The objective of this systematic review was to evaluate the current evidence on the utility of preoperative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide (NT-proBNP) in predicting short-term and long-term mortality after coronary artery bypass grafting (CABG). OVID MEDLINE, EMBASE, SCOPUS, and PUBMED were searched from 1946 to August 2022 using the following terms: "coronary artery bypass grafting" and "BNP" and "outcomes." Eligible studies included observational studies reporting the association between preoperative BNP and NT-proBNP levels and short- and long-term mortality after CABG. Articles were selected systematically, assessed for bias, and, when possible, meta-analyzed using a random effect model. After retrieving 53 articles, 11 were included for qualitative synthesis and 4 for quantitative meta-analysis. Studies included in this review showed that elevated preoperative natriuretic peptide levels, despite variable cut-offs, have been consistently shown to be associated with short- and long-term mortality after CABG. The median BNP cut-off value was 145.5 pg/mL (25th-75th percentile 95-324.25 pg/mL), and the mean NT-proBNP value was 765 ± 372 pg/mL. Compared to patients with normal natriuretic peptide levels, patients with elevated BNP and NT-proBNP presented higher mortality rates after CABG (odds ratio 3.96, 95% confidence interval 2.41-6.52; p < 0.00001). Preoperative BNP level is a powerful predictor of mortality in patients undergoing CABG. The measurement of BNP can add significant value to these patients' risk stratification and therapeutic decision-making.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. METHODS: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies). RESULTS: In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years. DISCUSSION: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Comparing mid-term outcomes of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A systematic review.

BACKGROUND: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-Maze procedure, which is currently the gold standard treatment for atrial fibrillation (AF), data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. OBJECTIVE: We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies comparing the mid-term mortality and recurrence of AF after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. METHODS: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. Additionally, a meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. RESULTS: Three RCTs and three observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that the concomitant Cox-Maze procedure was associated with higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimates pooled across the three RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (risk ratio = 1.58, 95% CI: 0.91-2.73). In two out of three higher-quality observational studies, 12-month AF recurrence was higher in PVI than in the Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated the survival benefit of Cox-Maze. CONCLUSIONS: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required to clarify the benefits of concomitant Cox-Maze in AF patients during MV surgery.

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial.

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. Design, Setting, and Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). Conclusions and Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. Trial Registration: isrctn.com Identifier: ISRCTN57819173.

Current trends in minimally invasive valve-sparing aortic root replacement-Best available evidence.

BACKGROUND: Valve-sparing aortic root replacement such as the reimplantation (David) procedure is becoming increasingly popular. Despite the fact that the procedure is technically more complex, long-term studies demonstrated that excellent clinical outcomes in selected patients with durable repair are achievable. Benefits of minimal access cardiac surgery have stimulated enthusiasm in the use of this access for valve-sparing aortic root replacement. METHODS: We have reviewed available literature on the topic of valve-sparing aortic root replacement (David procedure) via minimally invasive access through upper hemisternotomy in an attempt to assess current trends and to recognize potential advantages of this technique. Patient selection and preoperative work-up play important role in performing minimally invasive David procedure safely. Surgical technique corresponds to the standard David procedure, with a few exceptions related to the minimal access, and is performed via upper ministernotomy. RESULTS AND CONCLUSION: Evidence from nonrandomized observational and comparative studies demonstrated excellent clinical outcomes of minimally invasive David procedure in selected patients with comparable perioperative mortality and outcomes to the conventional technique. To date, David procedure with a minimal access technique has been performed in carefully selected patients. We believe it could be particularly beneficial to provide younger patients (Marfan syndrome and bicuspid aortic valve) with minimally invasive David procedure as it can allow faster recovery with improved cosmesis with excellent outcomes. A decision to perform minimally invasive David procedure should be individualized to each patient and based on the experience of the team. Further large prospective randomized studies with long-term follow-up are still needed to confirm durability of minimal access technique.

Rapid deployment technology versus conventional sutured bioprostheses in aortic valve replacement.

OBJECTIVES: Despite the benefits of rapid deployment aortic valve prostheses (RDAVR), conventional sutured valves (cAVR) are more commonly used in the treatment for aortic stenosis. Given the paucity of randomized studies, this study aimed to synthesize available data to compare both treatment options. METHODS: A systematic search of Pubmed, OVID, and MEDLINE was conducted to retrieve comparative studies for RDAVR versus cAVR in the treatment of aortic stenosis. Out of 1773 returned titles, 35 papers were used in the final analysis, including 1 randomized study, 1 registry study, 6 propensity-matched studies, and 28 observational studies, incorporating a total of 10,381 participants (RDAVR n = 3686; cAVR n = 6310). RESULTS: Random-effects meta-analysis found no difference between the two treatment groups in terms of operative mortality, stroke, or bleeding (p > .05). The RDAVR group had reduced cardiopulmonary bypass (standardized mean difference [SMD]: -1.28, 95% confidence interval [CI]: [-1.35, -1.20], p < .001) and cross-clamp times (SMD: -1.05, 95% CI: [-1.12, -0.98], p < .001). Length of stay in the intensive care unit was also shorter in the RDAVR group (SMD: -0.385, 95% CI: [-0.679, -0.092], p = .010). The risk of pacemaker insertion was higher for RDAVR (odds ratio [OR]: 2.41, 95% CI: [1.92, 3.01], p < .001) as was the risk of paravalvular leak (PVL) at midterm follow-up (OR: 2.52, 95% CI: [1.32, 4.79], p = .005). Effective orifice area and transvalvular gradient were more favorable in RDAVR patients (p > .05). CONCLUSIONS: Despite the benefits of RDAVR in terms of reduced operative time and enhanced recovery, the risk of pacemaker insertion and midterm PVL remains a significant cause for concern.

Do in-hospital outcomes of isolated coronary artery bypass grafting vary between male and female octogenarians?

OBJECTIVES: Female gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort. METHODS: All octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived. RESULTS: Five hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30-49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts. CONCLUSIONS: No gender difference in outcomes was seen in octogenarians undergoing isolated CABG.

A rare case of an intramyocardial mesothelial inclusion cyst.

A symptomatic intramyocardial cyst, whilst a rare occurrence, is most effectively investigated using Magnetic Resonance Imaging. Furthermore, following diagnosis it can be effectively treated using a surgical approach.

STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery.

INTRODUCTION: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. METHODS: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. RESULTS: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. CONCLUSION: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery.

Surgical pericardial heart valves: 50 Years of evolution.

Valve disease carries a huge burden globally and the number of heart valve procedures are projected to increase from the current 300 000 to 800 000 annually by 2050. Since its genesis 50 years ago, pericardial heart valve has moved leaps and bounds to ever more ingenious designs and manufacturing methods with parallel developments in cardiology and cardiovascular surgical treatments. This feat has only been possible through close collaboration of many scientific disciplines in the fields of engineering, material sciences, basic tissue biology, medicine and surgery. As the pace of change continues to accelerate, we ask the readers to go back with us in time to understand developments in design and function of pericardial heart valves. This descriptive review seeks to focus on the qualities of pericardial heart valves, the advantages, successes and failures encapsulating the evolution of surgically implanted pericardial heart valves over the past five decades. We present the data on comparison of the pericardial heart valves to porcine valves, discuss structural valve deterioration and the future of heart valve treatments.

The use of point-of-care testing in detecting platelet function recovery in a patient treated with prasugrel undergoing urgent surgical revascularization.

A recent administration of potent P2Y12 receptor inhibitor such as prasugrel in patients undergoing cardiac surgery remains a dilemma and little is known about its impact on platelet function recovery. Guidelines recommend discontinuation of prasugrel 7 days before surgery to reduce the risk of surgery-related bleeding. Patients at risk may benefit from preoperative platelet function testing to guide individualized preoperative waiting time. We present a rare case of complete function recovery in a patient treated with prasugrel revealed by preoperative platelet function monitoring before urgent coronary artery bypass surgery (CABG). A complete platelet function recovery was revealed by platelet function testing after discontinuation of prasugrel for four days and patient underwent urgent CABG without increased risk of postoperative bleeding. Our case with a review of literature emphasized that the decision to proceed with urgent CABG in a patient recently treated with prasugrel should be based on a personalized risk assessment and might be supported by preoperative platelet function monitoring to shorten the waiting time.

Recommendations for the use of coronary and valve simulators in cardiac surgical training: a systematic review.

OBJECTIVES: The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results. METHODS: A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed. RESULTS: Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established. CONCLUSIONS: Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest.

Surgical management of misdeployed transcatheter aortic valve due to eccentric leaflet calcification.

A serious complication of transcatheter valves is the mechanistic failure of the deployment system and prosthesis migration. We report the case of a transcatheter aortic valve implantation which failed during implantation resulting in dislodgement of the prosthesis. Emergency surgery to retrieve the deployment system and surgically replace the native valve was the only option to salvage the patient.

Characteristics of Randomized Clinical Trials in Surgery From 2008 to 2020: A Systematic Review.

Importance: Randomized clinical trials (RCTs) provide the highest level of evidence to evaluate 2 or more surgical interventions. Surgical RCTs, however, face unique challenges in design and implementation. Objective: To evaluate the design, conduct, and reporting of contemporary surgical RCTs. Evidence Review: A literature search performed in the 2 journals with the highest impact factor in general medicine as well as 6 key surgical specialties was conducted to identify RCTs published between 2008 and 2020. All RCTs describing a surgical intervention in both experimental and control arms were included. The quality of included data was assessed by establishing an a priori protocol containing all the details to extract. Trial characteristics, fragility index, risk of bias (Cochrane Risk of Bias 2 Tool), pragmatism (Pragmatic Explanatory Continuum Indicator Summary 2 [PRECIS-2]), and reporting bias were assessed. Findings: A total of 388 trials were identified. Of them, 242 (62.4%) were registered; discrepancies with the published protocol were identified in 81 (33.5%). Most trials used superiority design (329 [84.8%]), and intention-to-treat as primary analysis (221 [56.9%]) and were designed to detect a large treatment effect (50.0%; interquartile range [IQR], 24.7%-63.3%). Only 123 trials (31.7%) used major clinical events as the primary outcome. Most trials (303 [78.1%]) did not control for surgeon experience; only 17 trials (4.4%) assessed the quality of the intervention. The median sample size was 122 patients (IQR, 70-245 patients). The median follow-up was 24 months (IQR, 12.0-32.0 months). Most trials (211 [54.4%]) had some concern of bias and 91 (23.5%) had high risk of bias. The mean (SD) PRECIS-2 score was 3.52 (0.65) and increased significantly over the study period. Most trials (212 [54.6%]) reported a neutral result; reporting bias was identified in 109 of 211 (51.7%). The median fragility index was 3.0 (IQR, 1.0-6.0). Multiplicity was detected in 175 trials (45.1%), and only 35 (20.0%) adjusted for multiple comparisons. Conclusions and Relevance: In this systematic review, the size of contemporary surgical trials was small and the focus was on minor clinical events. Trial registration remained suboptimal and discrepancies with the published protocol and reporting bias were frequent. Few trials controlled for surgeon experience or assessed the quality of the intervention.

Emergency cardiac surgery for patients on NOACs in the NOAC era - Perspective.

Excessive bleeding is an important cause of morbidity and mortality after cardiac surgery. Bleeding after cardiac surgery is multifactorial. Adherence to the proverbial 6 Ps remains the cornerstone of any strategy for management of postoperative bleeding after cardiac surgery. Recent years have seen a surge in the number of patients who have been prescribed novel oral anticoagulants (NOACs) for the prevention and treatment of thromboembolic events. This phenomenon has significant repercussions particularly for patients presenting for emergency cardiac surgery. The published evidence guiding management of such patients is limited and in the form of expert consensus. Plasma levels of NOAC >30 ng/ml necessitate specific therapeutic interventions to tackle excessive bleeding attributed to NOAC intake. Current recommendation is to consider using specific reversal agent if available. Otherwise, use of prothrombin complex concentrates is recommended.