Incidence and Outcome of Surgical Procedures After Coronary Artery Bypass Grafting Compared With Those After Percutaneous Coronary Intervention

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Introduction

The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan.

Methods

In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs.

Results

A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery.

Conclusions

Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.

Relation of Previous Coronary Artery Bypass Grafting and/or Percutaneous Coronary Intervention to Perioperative Cardiovascular Outcomes in Patients Who Underwent Noncardiac Surgery

Patients with ischemic heart disease frequently undergo noncardiac surgery. We examined perioperative surgical outcomes in patients with and without previous coronary revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Adults ≥45 years old who underwent noncardiac surgery between 2010 and 2014 were identified from the National Inpatient Sample. Previous CABG and PCI were identified using International Classification of Diseases, Ninth Revision codes. Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as the composite of in-hospital mortality, acute myocardial infarction, and acute ischemic stroke. Multivariable logistic regression models were used to estimate associations between previous coronary revascularization and surgical outcomes after adjustment for clinical covariates. We identified 25,091,140 hospitalizations for noncardiac surgery, of which 8.4% had a history of coronary revascularization (47% previous CABG without PCI, 45% previous PCI without CABG, and 8% previous CABG and PCI). Hospitalized patients with versus without previous coronary revascularization had a higher crude incidence (4.0% vs 2.6%, p <0.001) but lower odds of MACCE (adjusted odds ratio 0.96, 95% CI 0.94 to 0.98) driven by a lower risk of death and ischemic stroke. When analyzed by revascularization strategy, lower odds of MACCE were restricted to patients with previous CABG, driven by excess perioperative acute myocardial infarction risks after PCI. In patients with established cardiovascular disease, previous coronary revascularization was associated with lower odds of MACCE (adjusted odds ratio 0.76, 95% CI 0.75 to 0.78), regardless of revascularization strategy. In conclusion, previous coronary revascularization is associated with lower odds of MACCE after noncardiac surgery, but perioperative risks vary by mode of coronary revascularization.

Is bariatric surgery safe in patients with history of cardiac revascularization?

BACKGROUND

The number of patients undergoing bariatric surgery with prior cardiac revascularization (CR) is rising. However, scarce data exist regarding the safety of bariatric procedures in these patients.

OBJECTIVES

The aim of this study is to compare postoperative cardiovascular and noncardiovascular outcomes among patients with different CR procedures.

SETTING

Academic hospital, United States.

METHODS

We retrospectively reviewed 2884 patients undergoing bariatric surgery from 2009-2018. Patients with prior CR were included and stratified into groups: coronary artery bypass graft (CABG), percutaneous coronary intervention with stent (PCI), and CABG + PCI. We described patient demographic characteristics, co-morbidities, smoking status, history of myocardial infarction, type of bariatric surgery, number of vessels grafted/stents, time from CR to bariatric surgery, length of stay, and cardiovascular and noncardiovascular 30-day outcomes. A control group composed of patients without prior CR undergoing bariatric surgery was used to compare the rate of complications to the total patients with prior CR. For continuous and categorical variables, t test and χ² tests were performed, respectively.

RESULTS

We identified 76 patients with prior CR undergoing bariatric surgery. The mean patient age was 61.4 ± 7.9 years, the mean body mass index was 41.7 ± 6.5 kg/m², and male sex was predominant (71.1%). Among these, 50% (n = 38) had PCI, 39.4% (n = 30) had CABG, and 10.5% (n = 8) had CABG + PCI. Early cardiovascular complications rate included ST-segment-elevation myocardial infarction (n = 2), pulmonary embolism (n = 1), supraventricular arrhythmia (n = 2), ventricular arrhythmia (n = 1), and pacemaker/defibrillator-insertion (n = 1). The overall rate of cardiovascular and noncardiovascular complications was 9.2% (n = 7) and 10.5% (n = 8) during the 30 days. Mortality rate was 0%. Comparison of rate of complications between groups did not show any statistical difference; no significant difference was found when comparing patients with prior CR to the 76 patients in the control group (P > .05).

CONCLUSIONS

Although revascularized individuals have severe co-morbidities and are high-risk patients, bariatric surgery remains safe in this population when outcomes are compared with bariatric patients without prior CR.

Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety

OBJECTIVE

To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y₁₂ inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications.

DATA SOURCES

A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations.

STUDY SELECTION AND DATA EXTRACTION

In all, 18 original research reports and case reports/series were included in the review.

DATA SYNTHESIS

Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y₁₂ inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding.

CONCLUSIONS

Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.

Impact of Transient or Persistent Contrast-induced Nephropathy on Long-term Mortality After Elective Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) is associated with increased long-term mortality. However, it is still controversial whether CIN is the cause of increased mortality or merely a marker of high-risk patients. The current study population included 5,516 patients who underwent their first elective percutaneous coronary intervention (PCI) in the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry cohort-2. CIN was defined as an elevation in the peak serum creatinine (SCr) of ≥0.5 mg/dl from the baseline within 5 days after PCI. CIN, seen in 218 patients (4.0%), was independently associated with an increased long-term mortality risk (hazard ratio [HR] 1.43, 95% confidence interval [CI],1.11 to 1.83; p = 0.005). SCr data at 1 year (180 to 550 days) after PCI were available in 3,986 patients, who were subdivided into persistent CIN (follow-up SCr elevation ≥0.5 mg/dl: n = 50 [1.3%]), transient CIN (follow-up SCr elevation <0.5 mg/dl: n = 90 [2.3%]), and non-CIN (n = 3,846 [96.5%]). In the landmark analysis at 1 year after PCI, 524 patients (13.1%) died during a median follow-up of 1,521 days. After adjustment for the 37 confounders, persistent CIN, but not transient CIN, was significantly correlated with a higher long-term mortality risk compared with non-CIN (HR 1.84, 95% CI 1.12 to 3.03; p = 0.02, and HR 1.11, 95% CI 0.71 to 1.76; p = 0.6, respectively). In conclusion, only persistent CIN was independently associated with increased long-term mortality.

Reliability and validity of the Korean version of the coronary revascularization outcome questionnaire

Background

People with ischemic heart disease have increased drastically, and their health-related quality of life (HRQOL) has been increasingly important. The Coronary Revascularization Outcome Questionnaire (CROQ) is a widely used tool to assess the quality of life in patients with coronary artery disease. The purpose of this study was to rigorously examine the psychometric properties of the CROQ in patients who had undergone percutaneous coronary intervention (PCI).

Methods

The CROQ was translated into Korean. A total of 209 patients before PCI and 169 patients after PCI were recruited from a university hospital in Korea and completed questionnaires. In terms of statistical analyses, internal consistency, concurrent validity with using the Short Form 12 (SF-12) and Seattle Angina Questionnaire-Korean version (SAQ-K), and construct validity using exploratory factor analysis were assessed. Effective size statistics were calculated.

Results

The internal consistency coefficients for all subscales of the CROQ were above 0.70, except the domain of adverse effects. The concurrent validity was mostly supported by the pattern of association among CROQ-K, SAQ-K, and SF-12. The results of EFA showed the core items of the CROQ had 7 factors. Large effect sizes were observed for the symptoms and the psychosocial functioning scales.

Conclusions

The Korean version of the CROQ is a valid and reliable scale for assessing HRQOL in patients with coronary artery disease.

Intra-aortic balloon pump-assisted major hepatectomy in a case with coronary disease

Clinically, we often encounter cancer patients who also have cardiovascular disease such as coronary artery disease. We experienced a case of severe coronary artery disease and a large hepatocellular carcinoma in a 69-year-old man. To reduce the risk of a perioperative cardiovascular event during mesohepatectomy, an elective intra-aortic balloon pump (IABP) was used. After an uneventful recovery, the patient was discharged on day 15. While IABP is frequently introduced in cardiac surgery, there have been few reports of its use during liver surgery. Here, we present IABP-assisted major hepatectomy as an option in a patient with both cancer and coronary artery disease.