Short- and long-term outcome after surgical aortic valve replacement in patients on dialysis

Background

Methods

Results

Conclusions

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.

Dextran-based priming solution during cardiopulmonary bypass attenuates renal tubular injury-A secondary analysis of randomized controlled trial in adult cardiac surgery patients

BACKGROUND

Acute kidney injury (AKI) is a well-known complication after cardiac surgery and cardiopulmonary bypass (CPB). In the present secondary analysis of a blinded randomized controlled trial, we evaluated the effects of a colloid-based versus a conventional crystalloid-based prime on tubular injury and postoperative renal function in patients undergoing cardiac surgery with CPB.

METHODS

Eighty-four adult patients undergoing cardiac surgery with CPB were randomized to receive either a crystalloid- or colloid- (dextran 40) based CPB priming solution. The crystalloid solution was based on Ringer-Acetate plus mannitol. The tubular injury biomarker, N-acetyl-b-D-glucosaminidase (NAG), serum creatinine and diuresis were measured before, during and after CPB. The incidence of AKI was assessed according to the KDIGO criteria.

RESULTS

The urinary-NAG/urinary-creatinine ratio rose in both groups during and after CPB, with a more pronounced increase in the crystalloid group (p = .038). One hour after CPB, the urinary-NAG/urinary-creatinine ratio was 88% higher in the crystalloid group (4.7 ± 6.3 vs. 2.5 ± 2.7, p = .045). Patients that received the dextran 40-based priming solution had a significantly lower intraoperative diuresis (p < .001) compared to the crystalloid group. The incidence of AKI was 18% in the colloid and 22% in the crystalloid group (p = .66). Postoperative serum creatinine did not differ between groups.

CONCLUSIONS

In patients undergoing cardiac surgery with CPB, colloid-based priming solution (dextran 40) induced less renal tubular injury compared to a crystalloid-based priming solution. Whether a colloid-based priming solution will improve renal outcome in high-risk cardiac surgery, or not, needs to be evaluated in future studies on higher risk cardiac surgery patients.

Markedly reduced myocardial expression of γ-protocadherins and long non-coding RNAs in patients with heart disease

BACKGROUND

Adverse cardiac remodeling and tissue damage following heart disease is strongly associated with chronic low grade inflammation. The mechanisms underlying persisting inflammatory signals are not fully understood, but may involve defective and/or non-responsive transcriptional and post-transcriptional regulatory mechanisms. In the current study, we aimed to identify novel mediators and pathways involved in processes associated with inflammation in the development and maintenance of cardiac disease.

METHODS AND RESULTS

We performed RNA sequencing analysis of cardiac tissue from patients undergoing coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) and compared with control tissue from multi-organ donors. Our results confirmed previous findings of a marked upregulated inflammatory state, but more importantly, we found pronounced reduction of non-protein coding genes, particularly long non-coding RNAs (lncRNA), including several lncRNAs known to be associated with inflammation and/or cardiovascular disease. In addition, Gene Set Enrichment Analysis revealed markedly downregulated microRNA pathways, resulting in aberrant expression of other genes, particularly γ-protocadherins.

CONCLUSIONS

Our data suggest that aberrant expression of non-coding gene regulators comprise crucial keys in the progression of heart disease, and may be pivotal for chronic low grade inflammation associated with cardiac dysfunction. By unmasking atypical γ-protocadherin expression as a prospective genetic biomarker of myocardial dysfunction, our study provides new insight into the complex molecular framework of heart disease. Creating new approaches to modify non-coding gene regulators, such as those identified in the current study, may define novel strategies to shift γ-protocadherin expression, thereby normalizing part of the molecular architecture associated with heart disease.

Life Expectancy After Surgical Aortic Valve Replacement

BACKGROUND

Surgical risk, age, perceived life expectancy, and valve durability influence the choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation. The contemporaneous life expectancy after SAVR, in relation to surgical risk and age, is unknown.

OBJECTIVES

The purpose of this study was to determine median survival time in relation to surgical risk and chronological age in SAVR patients.

METHODS

Patients ≥60 years with aortic stenosis who underwent isolated SAVR with a bioprosthesis (n = 8,353) were risk-stratified before surgery into low, intermediate, or high surgical risk using the logistic EuroSCORE (2001-2011) or EuroSCORE II (2012-2017) and divided into age groups. Median survival time and cumulative 5-year mortality were estimated with Kaplan-Meier curves. Cox regression analysis was used to further determine the importance of age.

RESULTS

There were 7,123 (85.1%) low-risk patients, 942 (11.3%) intermediate-risk patients, and 288 (3.5%) high-risk patients. Median survival time was 10.9 years (95% confidence interval: 10.6-11.2 years) in low-risk, 7.3 years (7.0-7.9 years) in intermediate-risk, and 5.8 years (5.4-6.5 years) in high-risk patients. The 5-year cumulative mortality was 16.5% (15.5%-17.4%), 30.7% (27.5%-33.7%), and 43.0% (36.8%-48.7%), respectively. In low-risk patients, median survival time ranged from 16.2 years in patients aged 60 to 64 years to 6.1 years in patients aged ≥85 years. Age was associated with 5-year mortality only in low-risk patients (interaction P < 0.001).

CONCLUSIONS

Eighty-five percent of SAVR patients receiving bioprostheses have low surgical risk. Estimated survival is substantial following SAVR, especially in younger, low-risk patients, which should be considered in Heart Team discussions.

Statins for secondary prevention and major adverse events after coronary artery bypass grafting

OBJECTIVE

The objective of this study was to evaluate the association of statin use after coronary artery bypass grafting (CABG) and long-term adverse events in a large population-based, nationwide cohort.

METHODS

All 35,193 patients who underwent first-time isolated CABG in Sweden from 2006 to 2017 and survived at least 6 months after surgery were included. Individual patient data from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and 4 other nationwide registries were merged. Multivariable Cox regression models adjusted for age, sex, comorbidities, and time-updated treatment with other secondary preventive medications were used to evaluate the associations between statin treatment and outcomes. The primary end point was major adverse cardiovascular events (MACE). Median follow-up time to MACE was 5.3 (interquartile range, 2.5-8.2) years.

RESULTS

Statins were dispensed to 95.7% of the patients six months after discharge and to 78.9% after 10 years. At baseline, 1.4% of patients were prescribed low-, 57.6% intermediate-, and 36.7% high-dose statins. Ongoing statin treatment was associated with markedly reduced risk of MACE (adjusted hazard ratio [aHR], 0.56 [95% CI, 0.53-0.59]), all-cause mortality (aHR, 0.53 [95% CI, 0.50-0.56]), cardiovascular death (aHR, 0.54 [95% CI, 0.50-0.59]), myocardial infarction (aHR, 0.61 [95% CI, 0.55-0.69]), stroke (aHR, 0.66 [95% CI, 0.59-0.73]), new revascularization (aHR, 0.79 [95% CI, 0.70-0.88]), new angiography (aHR, 0.81 [95% CI, 0.74-0.88]), and dementia (aHR, 0.74 [95% CI, 0.65-0.85]; all P < .01), irrespective of the statin dose.

CONCLUSIONS

Ongoing statin use was associated with a markedly reduced incidence of adverse events and mortality after CABG. Initiating and maintaining statin medication is essential in CABG patients.

Outcome after surgery for acute type A aortic dissection with or without primary tear resection

BACKGROUND

The outcome in patients after surgery for acute type A aortic dissection without replacement of the part of the aorta containing the primary tear is undefined.

METHODS

Data of 1122 patients who underwent surgery for acute type A aortic dissection in eight Nordic centers from Jan 2005 to Dec 2014 were retrospectively analyzed. The patients with primary tear location either unfound, unknown, not confirmed or not recorded (n=243, 21.7%) were excluded from the analysis. The patients were divided into two groups according to whether the aortic reconstruction encompassed the portion of the primary tear (TR group, n=730) or not (TNR group, n=149). The restricted mean survival time ratios adjusted for patient characteristics and surgical details between the groups were calculated for all-cause mortality and aortic reoperation-free survival. The median follow-up time was 2.57 (inter-quartile range 0.53-5.30) years.

RESULTS

For the majority of the patients in the TR group, the primary tear was located in the ascending aorta (83.6%). The reconstruction encompassed both aortic root and the aortic arch in 7.4% in the TR group as compared with 0.7% in the TNR patients (P<0.001). There were no significant differences in all-cause mortality (adjusted restricted mean survival time ratio 1.01, 95% confidence interval 0.92-1.12, P=0.799) or reoperation-free survival (adjusted restricted mean survival time ratio 0.98, 95% confidence interval 0.95-1.02, P=0.436) between the TR group and TNR groups.

CONCLUSIONS

Primary tear resection alone does not determine the mid-term outcome after surgery for acute type A aortic dissection.

A comparison of the in vitro effects of three fibrinogen concentrates on clot strength in blood samples from cardiac surgery patients

BACKGROUND

Fibrinogen concentrate is used clinically to improve hemostasis in bleeding patients. We investigated and compared the efficacy of three commercially available fibrinogen concentrates to improve clot strength in blood samples from cardiac surgery patients.

OBJECTIVES

Postoperative blood samples were collected from 23 cardiac surgery patients. Samples were each divided into four vials, each supplemented with 1.125 mg of fibrinogen of one of three fibrinogen concentrates (RiaSTAP^® , Fibryga^® , FibCLOT^® ), or placebo. The fibrinogen dose corresponded to 2.5 g per 70 kg of body weight. Clot strength after supplementation was assessed in duplicate with rotational thromboelastometry (ROTEM^® ) using FIBTEM maximum clot firmness, EXTEM clot formation time, and maximum clot firmness assays.

RESULTS

In vitro fibrinogen concentrate supplementation of the samples resulted in higher plasma fibrinogen concentrations and improved clot strength with all three concentrates. Supplementation with FibCLOT increased FIBTEM maximum clot firmness (+46% [25th-75th percentile 35-55] compared to placebo) significantly more than did supplementation with Fibryga (+26% [21-35]) and RiaSTAP (+29% [22-47], p < .001). FibCLOT supplementation also shortened EXTEM clot formation time and increased EXTEM maximum clot firmness to a greater extent than did the other concentrates (both p < .001).

CONCLUSIONS

At the selected dose, FibCLOT was more effective than Fibryga and RiaSTAP in restoring clot strength in postoperative blood samples from cardiac surgery patients. These results may have implications for the choice of fibrinogen concentrate and dosing.

CHA2DS2-VASc below 3 predicts low one-year ischemic stroke risk in postoperative atrial fibrillation after CABG

Background

Ischemic stroke prevention is a major goal in patients with atrial fibrillation (AF). Neither the optimal risk assessment method, nor the risk-benefit-ratio of long-term use of oral anticoagulation (OAC) is, however, known in patients with new-onset AF (POAF) after cardiac surgery.

Purpose

To explore the feasibility of using the CHA2DS2-VASc scoring system in predicting the one-year ischemic stroke risk in patients with POAF after coronary artery bypass grafting (CABG).

Methods

All patients in Sweden with POAF after isolated CABG 2007–2017, with at least one year of follow-up, and without oral anticoagulation (OAC), were included in this observational, registry-based cohort study. POAF was defined as any new-onset AF during the index hospitalization for CABG. Primary endpoint was the one-year ischemic stroke risk at each step of the CHA2DS2-VASc score in POAF patients with at least one-year follow-up.

Results

Out of 6368 POAF patients without OAC neither at hospital discharge nor before the occurrence of events, 4467 (70.1%) had at least one year follow-up with altogether 124 ischemic strokes within one year from discharge. The one-year risk for ischemic stroke was &lt;1% for a CHA2DS2-VASc score &lt;3, 1–2% for a CHA2DS2-VASc score 3, and &gt;2% for a CHA2DS2-VASc score ≥4. The area under the receiver-operating-characteristic curve for predicting ischemic stroke was 0.67 (95% CI 0.64–0-69).

Conclusions

The CHA2DS2-VASc score was suitable for predicting low risk for ischemic stroke during the first year after hospital discharge in patients with POAF after CABG. A risk &lt;1% considered low was, however, observed at a considerably higher score than in patients with non-surgical/non-valvular AF described in previous studies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Heart-Lung Foundation (grant 20150587 and 20180560 to Anders Jeppsson)Region Västra Götaland (grant VGFOUREG-847811 to Anders Jeppsson and grant VGFOUREG-648981 to Amar Taha) Event rates during one year

Post-discharge major bleeding, myocardial infarction and mortality risk after coronary artery bypass grafting: a nationwide cohort study from the SWEDEHEART registry

Background

Platelet inhibition and occasionally oral anticoagulants are used after coronary artery bypass grafting (CABG) to reduce ischaemic events but may increase bleeding risk. The impact of post-discharge major bleeding and myocardial infarction on mortality risk in CABG patients is unknown.

Methods

All patients who underwent first-time isolated CABG in Sweden 2006–2017 and survived 14 days after discharge were included. Individual patient data from five mandatory national registries (SWEDEHEART, National Patient Register, Swedish Prescribed Drug Register, Cause of Death Register and The Swedish Population Register) were merged. Post-discharge major bleeding and myocardial infarction were defined as hospitalization with a bleeding or myocardial infarction diagnosis as main diagnosis respectively. A Cox proportional piecewise hazard model for the effect of time-updated bleeding and myocardial infarction as first post-discharge event on subsequent mortality risk was developed. The model was adjusted for age, sex, year of surgery, comorbidities at baseline and time-updated use of platelet inhibitors, oral anticoagulants and other secondary prevention medications. To estimate the time-dependent risk on mortality after an event, hazard ratios were calculated for &lt;30 days, 30–365 days and &gt;365 days after first incidence of major bleeding and myocardial infarction.

Results

In total 36 633 patients were included and median follow-up was 6.0 years (25th-75th percentile 3.0–9.0 years). During follow-up, 2265 (6.2%) patients suffered a major bleeding and 2108 (5.8%) patients a myocardial infarction as a first post-discharge event. In total 6683 (18.2%) died during follow-up. Both major bleeding and myocardial infarction were significantly associated with increased mortality risk compared to patients without any major bleeding or myocardial infarction. The adjusted hazard ratios for mortality &lt;30 days after major bleeding were 21.45 (95% CI 18.27–25.20) and 22.00 (95% CI 18.29–26.45) after myocardial infarction, 4.04 (95% CI 3.57–4.56) and 4.54 (95% CI 3.88–5.31) 30–365 days after the event and 1.57 (95% CI 1.43–1.72) and 2.07 (95% CI 1.86–2.30) &gt;365 days after the event, all compared to patients without major bleeding or myocardial infarction.

Conclusion

Major bleeding and myocardial infarction as first post-discharge event after CABG had similar incidence and were associated with a significant and comparable increase in mortality risk. The risk was highest during the first 30 days after the event. Strategies to prevent myocardial infarction and major bleeding events after CABG are of great importance to improve survival.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Heart-Lung FoundationSparbanken Sjuhärads stiftelse för forskning vid Södra Älvsborgs Sjukhus Forest plot

Short- and long-term mortality after deep sternal wound infection following cardiac surgery: experiences from SWEDEHEART

OBJECTIVES

Deep sternal wound infection (DSWI) is a serious complication after open-heart surgery. We investigated the association between DSWI and short- and long-term all-cause mortality in a large well-defined nationwide population.

METHODS

A retrospective, nationwide cohort study, which included 114676 consecutive patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery from 1997 to 2015 in Sweden. Short- and long-term mortality was compared between DSWI patients and non-DSWI patients using propensity score inverse probability weighting adjustment based on patient characteristics and comorbidities. Median follow-up was 8.0 years (range 0-18.9).

RESULTS

Altogether, 1516 patients (1.3%) developed DSWI, most commonly in patients undergoing combined CABG and valve surgery (2.1%). DSWI patients were older and had more disease burden than non-DSWI patients. The unadjusted cumulative mortality was higher in the DSWI group compared with the non-DSWI group at 90 days (7.9% vs 3.0%, P < 0.001) and at 1 year (12.8% vs 4.5%, P < 0.001). The adjusted absolute difference in risk of death was 2.3% [95% confidence interval (CI): 0.8-3.9] at 90 days and 4.7% (95% CI: 2.6-6.7) at 1 year. DSWI was independently associated with 90-day [adjusted relative risk (aRR) 1.89 (95% CI: 1.38-2.59)], 1-year [aRR 2.13 (95% CI: 1.68-2.71)] and long-term all-cause mortality [adjusted hazard ratio 1.56 (95% CI: 1.30-1.88)].

CONCLUSIONS

Both short- and long-term mortality risks are higher in DSWI patients compared to non-DSWI patients. These results stress the importance of preventing these infections and careful postoperative monitoring of DSWI patients.

Long-term mortality in patients with ischaemic heart failure revascularized with coronary artery bypass grafting or percutaneous coronary intervention: insights from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Aims 

To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of patients with heart failure due to ischaemic heart disease.

Methods and results 

We analysed all-cause mortality following CABG or PCI in patients with heart failure with reduced ejection fraction and multivessel disease (coronary artery stenosis >50% in ≥2 vessels or left main) who underwent coronary angiography between 2000 and 2018 in Sweden. We used a propensity score-adjusted logistic and Cox proportional-hazards regressions and instrumental variable model to adjust for known and unknown confounders. Multilevel modelling was used to adjust for the clustering of observations in a hierarchical database. In total, 2509 patients (82.9% men) were included; 35.8% had diabetes and 34.7% had a previous myocardial infarction. The mean age was 68.1 ± 9.4 years (47.8% were >70 years old), and 64.9% had three-vessel or left main disease. Primary designated therapy was PCI in 56.2% and CABG in 43.8%. Median follow-up time was 3.9 years (range 1 day to 10 years). There were 1010 deaths. Risk of death was lower after CABG than after PCI [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.41–0.96; P = 0.031]. The risk of death increased linearly with quintiles of hospitals in which PCI was the preferred method for revascularization (OR 1.27, 95% CI 1.17–1.38, P  _trend < 0.001).

Conclusion 

In patients with ischaemic heart failure, long-term survival was greater after CABG than after PCI.

Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome

IMPORTANCE

Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.

OBJECTIVE

To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.

EXPOSURES

Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.

MAIN OUTCOMES AND MEASURES

Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.

RESULTS

A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results.

CONCLUSIONS AND RELEVANCE

In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.

Glucosylceramide synthase deficiency in the heart compromises β1-adrenergic receptor trafficking

Aims 

Cardiac injury and remodelling are associated with the rearrangement of cardiac lipids. Glycosphingolipids are membrane lipids that are important for cellular structure and function, and cardiac dysfunction is a characteristic of rare monogenic diseases with defects in glycosphingolipid synthesis and turnover. However, it is not known how cardiac glycosphingolipids regulate cellular processes in the heart. The aim of this study is to determine the role of cardiac glycosphingolipids in heart function.

Methods and results 

Using human myocardial biopsies, we showed that the glycosphingolipids glucosylceramide and lactosylceramide are present at very low levels in non-ischaemic human heart with normal function and are elevated during remodelling. Similar results were observed in mouse models of cardiac remodelling. We also generated mice with cardiomyocyte-specific deficiency in Ugcg, the gene encoding glucosylceramide synthase (hUgcg  ^–/– mice). In 9- to 10-week-old hUgcg  ^–/– mice, contractile capacity in response to dobutamine stress was reduced. Older hUgcg  ^–/– mice developed severe heart failure and left ventricular dilatation even under baseline conditions and died prematurely. Using RNA-seq and cell culture models, we showed defective endolysosomal retrograde trafficking and autophagy in Ugcg-deficient cardiomyocytes. We also showed that responsiveness to β-adrenergic stimulation was reduced in cardiomyocytes from hUgcg  ^–/– mice and that Ugcg knockdown suppressed the internalization and trafficking of β1-adrenergic receptors.

Conclusions 

Our findings suggest that cardiac glycosphingolipids are required to maintain β-adrenergic signalling and contractile capacity in cardiomyocytes and to preserve normal heart function.

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discusses strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.

A randomized prospective multicenter trial for stroke prevention by prophylactic surgical closure of the left atrial appendage in patients undergoing bioprosthetic aortic valve surgery--LAA-CLOSURE trial protocol

Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation.

Secondary prevention medications after coronary artery bypass grafting and long-term survival: a population-based longitudinal study from the SWEDEHEART registry

Aims

To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin–angiotensin–aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality.

Methods and results

All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52–0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73–0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69–0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P < 0.001). There was no association between β-blockers and mortality risk (HR 0.97, 95% CI 0.90–1.06; P = 0.54).

Conclusion

The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned.

Factor XIII activity at onset of labour and association with postpartum haemorrhage: an exploratory post-hoc study

BACKGROUND

Platelets, fibrinogen and factor XIII (FXIII) are required to form a stable clot in case of haemorrhage. The aims of this study were to evaluate a possible association between FXIII activity at the onset of labour and postpartum haemorrhage (PPH), and to ascertain whether FXIII activity at labour onset differs from after delivery.

METHODS

FXIII activity in 239 women with PPH (blood loss >1 L) and in 76 women without PPH was compared, as was activity before and after delivery in a third group of 80 women.

RESULTS

FXIII activity at onset of labour was significantly lower in the PPH group compared with the control group (mean ± SD 0.98 ± 0.20 vs 1.05 ± 0.17 kIU/L; P=0.0006). The difference was significantly greater in subgroups having vaginal delivery with no oxytocin stimulation or uterine exploration (absolute difference 0.131; 95% CI 0.055 to 0.206), compared with a subgroup experiencing any complication (0.04; 95% CI -0.023 to 0.104; interaction P-value 0.098). There was a weak but statistically significant inverse correlation between FXIII and estimated blood loss (r=-0.25; P=0.030) in the control group but not the PPH group. There was no significant difference between FXIII activity at onset of labour and after delivery (mean ± SD 1.03 ± 0.17 vs 1.04 ± 0.19 kIU/L; P=0.093).

CONCLUSIONS

At the onset of labour women with a subsequent PPH had significantly lower mean FXIII activity than that of women without PPH. This difference was small and within normal limits. FXIII activity did not change during normal delivery. The importance of FXIII during PPH requires study.

The risk of dementia after coronary artery bypass grafting in relation to age and sex

Introduction

We examined the long‐term risk of dementia after coronary artery bypass grafting (CABG) in relation to age and sex.

Methods

All CABG patients in Sweden 1992–2015 (n = 111,335), and matched controls (n = 222,396) were included in a population‐based study. Adjusted hazard ratios (aHR) for all‐cause dementia, vascular dementia, and Alzheimer's disease were calculated.

Results

There was no difference in the risk for all‐cause dementia between CABG patients and control subjects (aHR 0.98 [95% confidence interval 0.95 to 1.02]). CABG patients <65 years and 65 to 74 years had higher risk (aHR 1.29 [1.17–1.42] and 1.08 [1.02–1.13], respectively), and patients ≥75 years had lower risk (aHR 0.76 [0.71–0.81]). The highest risk was observed in women <65 years (aHR 1.64 [1.31–2.05]).

Discussion

Overall, the long‐term risk for all‐cause dementia does not differ between CABG patients and the general population. Younger patients have a higher risk, while older patients have a lower risk, compared to controls.

Arachidonic acid-induced platelet aggregation and acetylsalicylic acid treatment during pregnancy in women with recurrent miscarriage, a post hoc study

In this post hoc study, arachidonic acid (AA)-induced platelet aggregation during pregnancy with and without acetylsalicylic acid (ASA) treatment was studied in 323 women with unexplained recurrent first-trimester miscarriage and in 59 healthy women with normal pregnancies. All women had normal AA-induced platelet aggregation in the non-pregnant state. Women with recurrent miscarriage were treated with 75 mg ASA or placebo daily. AA-induced platelet aggregation was measured with multiple electrode impedance aggregometry and presented in units (U), where 1 U = 10 aggregation units x minutes. There were no significant differences in platelet aggregation between placebo-treated women with recurrent miscarriage and healthy women. The mean differences were-0.7 (95%CI; -7.0; 5.6) U in the non-pregnant state, 3.8 (95%CI; -4.6; 12.2) U during the late first trimester and 1.7 (95%CI; -6.7; 10.3) U and 4.1 (95%CI; -3.9; 12.0) U during the early and late third trimester, respectively. ASA reduced platelet aggregation by median -84.0% (Q1; Q3; -89.8; -76.3), -79.9% (-84.7; -69.2) and -75.7% (-83.5; -49.5), respectively, during pregnancy. The degree of inhibition by ASA decreased during the third trimester (p < .0001). There were two (1.9%) complete non-responders to ASA and 32.1% with a partial response. The rate of subsequent miscarriage was not affected by ASA, which did not seem to influence the rate of early miscarriage if treatment was initiated when a viable pregnancy was detectable by ultrasound.

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is 'heart teams'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discuss strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.