Statin therapy in the primary prevention of early atrial fibrillation after coronary artery bypass grafting

OBJECTIVE

Assessment of the role of statin therapy in the prevention of postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) in patients without prior atrial fibrillation.

METHODS

A retrospective analysis of 206 patients, aged 57.2±7.9 years (mean±SD), who underwent isolated CABG is carried out. All patients are divided into two groups. The first group (nSt-patients) includes the patients who did not receive statin therapy prior to CABG (n=82). The second group (St-patients) includes the patients who received statin therapy prior to CABG (n=124). Both groups received the statin therapy from the first day after CABG. The risk of occurrence of POAF is evaluated using the Cox-regression model.

RESULTS

The rate of POAF was 25.6% in nSt-patients and 6.5% in St-patients (P=0.020). On the 4th day after CABG, white blood cells (WBC) count was 11.0 (9.0, 13.0)×10⁹/mL (medians with inter-quartile ranges) in nSt-patients and 9.0 (7.6, 10.2)×10⁹/mL in St-patients (P<0.001). The peak WBC numbers occurred on the day of POAF onset. The Cox-regression analysis shows that only two factors (statin therapy and number of grafts) had significant influence on the POAF onset. Odds ratio of POAF event prediction by statin therapy was 0.20 (95%CI: 0.08-0.51), P<0.001. Each subsequent graft increased the risk of POAF in 2.1 times.

CONCLUSION

Statin therapy carried out prior to the CABG is an effective approach to primary prevention of POAF in early postoperative period. Statin therapy after CABG in nSt-patients does not give prophylactic effect observed in St-patients.

[The possibility of selecting optimal antiplatelet therapy in patients with coronary heart disease in terms of CYP2C19 polymorphism]

AIM

To estimate whether optimal antiplatelet therapy can be selected in terms of CYP2C19 polymorphism.

SUBJECTS AND METHODS

The prospective randomized trial included 124 patients (93 men and 31 women) who were to undergo percutaneous coronary intervention. They initially received dual antiplatelet therapy: clopidogrel 75 mg + acetylsalicylic acid (ASA) 300 mg. Genetic testing was performed in all the patients to reveal the carriage of allelic variants of the genes of cytochrome P-450 isoenzymes and the efficiency of antiplatelet therapy was evaluated. The carriers of one allele (CYP2C19*2/*1) were randomized into 3 subgroups according to further antiplatelet therapy. The therapy was not changed in Subgroup 1. The dose of clopidogrel was increased up to 150 mg/day and that of ASA remained unchanged in Subgroup 2. In Subgroup 3, the therapy was completely changed to the regimen: ASA 300 mg + ticagrelor 90 mg twice daily. Three days later, platelet aggregation was reinvestigated in all the three subgroups.

RESULTS

In our investigation, the prevalence of carriage of at least one of the CYP2C19*2 alleles was about 35%. Comparison of the baseline platelet aggregation levels during the same platelet therapy showed statistically significant differences between the carriers and non-carriers: 32.7±11.6 and 44.8±12.9 (p=0.0024). Compared with the baseline values, there was a drug therapy switching-induced reduction in platelet aggregation in Subgroups 2 and 3 (p=0.0001 and p=0.0056, respectively). No statistically significant differences were found in Subgroup 1.

CONCLUSION

The determination of CYP2C19 gene polymorphism allows a personalized approach to be applied in antiplatelet therapy for all patients with coronary artery disease.

[Efficacy of Statin Therapy in the Prevention of Atrial Fibrillation in Early Postoperative Period after Coronary Artery Bypass Grafting]

BACKGROUND

The incidence of the postoperative atrialfibrillation (POAF) after open heart surgery is up to 65%. Statin therapy has shown conflicting data in the prevention of the POAF.

OBJECTIVE

Our aim was eo evaluate the role of statin therapy in the primary prevention of AF after CABG.

METHODS

Group 1 (n = 82) included those patients who received no statin therapy and the Group 2 (n = 124) included those patients who did receive statin therapy for at least three days prior to the operation and for all days in the postoperative period. WBC count in different periods after surgery and rate of AF were evaluated. The risk of occurrence of postoperative AF was evaluated using the Cox-regression model and odds ratio.

RESULTS

A retrospective analysis of 206 medical records of the patients without pre-existing AF after CABG was performed. The rate of AF was 26% in Group 1 and 6.5 % in Group 2 (p = 0.0001). On Day 4 after surgery, WBC count was 11 (9;13) in the first group and 9 (7.6;10.2) x 10(9) e/L in the second group (p = 0.000001). "Statin use" and "number of grafts" and were found to be statistically meaningful: p = 0.002 and p = 0.0125 respectively (χ2 = 28.3; p < 0.001). In accordance with the Cox model of regression, the risk of AF was 0.201 for "statin use"; and 2.099 for "number of grafts". Odds ratio was 0.2 (95% CI 0.08-0.5).

CONCLUSION

Statin therapy prior to and after GABG wasfound to be an effective method of primary prevention of AF in the early postoperative period.

Deep Learning-Based Image Registration in Dynamic Myocardial Perfusion CT Imaging

Registration of dynamic CT image sequences is a crucial preprocessing step for clinical evaluation of multiple physiological determinants in the heart such as global and regional myocardial perfusion. In this work, we present a deformable deep learning-based image registration method for quantitative myocardial perfusion CT examinations, which in contrast to previous approaches, takes into account some unique challenges such as low image quality with less accurate anatomical landmarks, dynamic changes of contrast agent concentration in the heart chambers and tissue, and misalignment caused by cardiac stress, respiration, and patient motion. The introduced method uses a recursive cascade network with a ventricle segmentation module, and a novel loss function that accounts for local contrast changes over time. It was trained and validated on a dataset of n = 118 patients with known or suspected coronary artery disease and/or aortic valve insufficiency. Our results demonstrate that the proposed method is capable of registering dynamic cardiac perfusion sequences by reducing local tissue displacements of the left ventricle (LV), whereas contrast changes do not affect the registration and image quality, in particular the absolute CT (HU) values of the entire CT sequence. In addition, the deep learning-based approach presented reveals a short processing time of a few seconds compared to conventional image registration methods, demonstrating its application potential for quantitative CT myocardial perfusion measurements in daily clinical routine.

[A. N. Bakoulev Scientific Center for Cardiovascular Surgery]

OBJECTIVE

to assess dynamics of diastolic function for detection of development of diastolic dysfunction (DD) and it's causes, to evaluate the effect of DD on prognosis in the postoperative period in patients with acquired heart diseases.

MATERIALS AND METHODS

We included in this study 112 patients with aortic and mitral valve diseases (90 men, 22 women, median age 51 [35; 57] years). All patients underwent echocardiography (echo), tissue Doppler, speckle tracking echo prior to surgery, in the early postoperative period (8-14 days) and in 12-36 months after surgery. In 28 patients dynamic contrast-enhanced magnetic resonance imaging was also performed. Patients were divided into groups according to prognosis: group 0 - without complications; group 1 - with postoperative heart failure (HF) and preserved left ventricular ejection fraction (EF); group 2 - with HF and EF &lt;45 %. The following parameters were used for identifying left ventricular (LV) DD: septal velocity es &lt;7 cm / sec, lateral el &lt;10 cm / sec, average E / e ratio &gt;14, left atrial (LA) volume index &gt;34 ml / m2, peak tricuspid regurgitation velocity &gt;2.8 m / sec.

RESULTS

Initially diastolicLV function was normal in 34 of 112 patients (30.4 %), in early postoperative period DD emerged in 9 (26.5 %) of these patients. The appearance of LV DD was associated with decrease of septal es immediately after surgery and its subsequent progressive decline in the long-term postoperative period from 8.5±0.71 to 4.6 ±0.53 cm / sec (p=0.005). Worsening of diastolic function and lowering of septal velocity was detected namely in patients with presence of fibrosis. In the group of other patients in whom fibrosis was not studied and the degree of DD increased there was a transient decrease of lateral el (from 10.2±3.1 to 7.5±2.43 cm / sec, p=0.035) and an increase of the E / el (from 10.53±4.07 to 14.5±5.23, p=0.05) in the early period after the operation. There were no correlations between DD and LV EF,LV volumes, and development of arrhythmias. The prognostic model for DD included average longitudinal deformation of LA (global LA longitudinal strain) and E / e ratio on the tricuspid lateral annular velocity.

CONCLUSIONS

Appearance of DD in postoperative period after correction of acquired heart defects was due to damage of the septal diastolic function which correlated with fibrosis and was indicative of inadequate myocardial protection. The model of development of heart failure with normal EF after operation was designed.

2226The randomised study of epicardial application of hydrogel with amiodarone for prevention of postoperative atrial fibrillation in patients after coronary artery bypass grafting

Material and methods

We present an open prospective randomised study, in which 60 patients (47 male), mean age of 62±8,5 were included. Baseline clinical, laboratory and instrumental characteristics were similar in all patients. Patients didn't have any arrhythmic complains or previously registered AF. All patients underwent elective CABG and were randomised into two groups: Group #1 (n=30) - had the amiodarone-releasing hydrogel application before chest closure, and Group #2 (n=30) regular CABG surgery, no local application. We used 60 mg of amiodarone in hydrogel. This dose was experimentally determined during previously performed animal study. Heart rhythm control was monitored continuously during first 5 postoperative days and occasionally (mornings and evenings) the remaining days before the discharge. The local ethics committee approved this study design.

Results

The incidence of postoperative AF occurrence was significantly lower in Group #1: AF was registered in 3.3% cases versus 37% of patients from Group #2 (p<0.001). There was slight increase of PQ interval duration in Group #1 - 0.14 sec (0.12; 0.16), which however was significantly higher then in Group #2 - 0.12 (0.12; 0.14), (p<0.01). QRS and QT intervals were similar in both groups without significant difference.

There were no complications associated with the application procedure neither during postoperative period, such as AV block, infection or life-threatening situations.

According to 5 days ECG monitoring, the average heart rate in the Group #1 was 59 (52; 60) beats per min versus 69 beats per min (65; 75) in Group #2 (p<0.001). Temporary atrial or atrio-ventricular pacing used for correction of the heart rate if required in both groups. By the time of discharge none of the patients required permanent cardiac pacing. The length of stay in Group #1 was significantly shorter: 6 (6; 7) days versus 8 (8; 9) days (p<0,001).

Among all studied parameters, amiodarone-releasing hydrogel application and older age were statistically significant in postoperative AF occurrence (p<0.01). According to the Cox regression model amiodarone-releasing hydrogel application decreases the incidence of postoperative AF by 18,9 folds. The older age instead increases the incidence of postoperative AF by 1,2 folds.

Conclusions

The local epicardial amiodarone (60 mg) application in hydrogel before chest closure is a safe procedure. This approach showed it's effectiveness in AF prevention in patient undergoing elective CABG.

[The Use of Novel Technologies for Assessment of Myocardial Function in Clinical Practice]

Key factors defining the prognosis of patients with heart failure (HF) are cardiac remodeling and myocardial contractility. New methods of visualization of myocardial motion gave impulse to research in the area of heart physiology and pathology. However in clinical practice these methods are still rarely used. Evaluation of systolic and diastolic functions based on tissue Doppler (TD), 2D and 3D speckle tracking data provides information on the pressure of left ventricular (LV) filling and enables carrying out differential diagnosis between constrictive pericarditis and myocardial diseases with diastolic dysfunction, dyspnea caused by cardiac and extracardiac causes. It also helps to understand physiology of systolic and diastolic dysfunction, impairment of LV pump function. It also enables monitoring response to HF treatment. Myocardial function analysis gives an opportunity to carry out early diagnostics, to detect subclinical LV dysfunction, to detect dyssynchrony and to predict response to resynchronising therapy. In this article we sum up indicators of systolic and diastolic dysfunction in various types of pathology and present assessment of mechanical dyssynchrony with the aid of TD, 2D and 3D speckle tracking. It is stressed that these methods allow carrying out quantitative analysis of myocardial motion. Practically all analyzed parameters are nonspecific and similar to parameters of remodeling change unidirectionally irrespective of pathology. The aim of this article is to summarize available data and knowledge on the determination of myocardial function. This is important for clinical practice and understanding of future development of the above methods.

P2507Role of “Walk with a doc” program practice in total risk approach to prevention of cardiovascular disease in RF

Background

It is known that life-style related factors are the main risk factors for CVD morbidity and mortality. In countries with economies in transition (such as Russia) many efforts were aimed at CVD diagnostic and treatment procedures improvement, but lack of primary prevention strategies is observed in general population. CVD morbidity and mortality could be prevented through population based strategies.

Purpose

To evaluate the feasibility and potency of implementing “Walk with a doc” program practice using newly-developed “Cardiac numbers Diary” for estimation of the individual risk on making decision about whether to initiate specific preventive action to reduce CVD morbidity.

Methods

The program has successfully started in Moscow, RF in July 2012 as a Russian branch of the global “Walk with a doc” activity. As of January 2019 there are 1576 participants in the database. Special “Cardiac numbers Diary” was developed and includes special charts to allow the introduction of the total risk stratification approach for management of CVD. The charts use a modelling approach with age, sex, physical activity, smoking, blood pressure, body weight, blood glucose and cholesterol. With support of center specialists the weekly events are carried out in different open space grounds and include the assessment of the above risk factors, life style modifying counseling including lectures and 35–40 minutes' walk at the moderate pace. 150 participants participated in more than 20 walks mean age 58,2 years old (±17,1) were assessed in this prospective study. They were assessed for risk factors modifying in 6 months follow-up period. At the moment of inclusion 37.5% participants had arterial hypertension, 12.1% were smokers, 20.2% were overweight. The official Walk-with-a-doc movement is registered in RF. Special Web site provides information on future events, physician team, life-style, diet, physical activity recommendations, photo materials and etc.

Results

After 6 month of regular walking the number of hypertensive participants decreased to 20.2%. 9.4% of all participants were able to lose weight by 1–6 kg, and 33.3% quit smoking. 75% of people who walked noticed an increase in the level of physical activity. 17.3% of them underwent inpatient treatment using high-tech medical care. Ther were no major events in the above cohort of patients.

Conclusions

“Walk with a doc” program practice using newly-developed individual “Cardiac numbers Diary” for a predicted individual risk with regular professional counseling can be a useful guide for making clinical decisions on the intensity of preventive interventions to reduce cardiovascular risk factors in general population.

Acknowledgement/Funding

None

[Opportunities Provided by Stress Echocardiography and Stress Speckle tracking for the Evaluation of Myocardial Reserve Among Patients With Heart Defects]

Heart failure risk factors research as well as studies of myocardial dysfunction to identify subclinical heart disease are important problems that can be solved with stress echocardiography and new methods of myocardial function analysis. Key factors defining the prognosis of patients with valvular diseases are heart remodeling and myocardial contractility. Heart remodeling types have been studied in detail by the present time. Elucidation of capability of stress echocardiography to detect asymptomatic dysfunction and assess prognosis of the results of surgery is continuing. Most important technological achievements of the last ten years gave us the opportunity to quantitatively assess myocardial function and movement. Tissue Doppler and Speckle Tracking enabled us to find alternative to invasive methods way to determination of parameters of global and regional myocardial function. Nowadays the first research results on the use of Speckle Tracking to estimate the contractile reserve are appearing. A high prognostic significance of global longitudinal deformation has been revealed. The aim of this article is to summarize available data on assessment of severity of valvular heart disease and the state of myocardial contractile reserve using stress echocardiography, Tissue Doppler and Speckle tracking data.

Home monitoring program for patients following cardiac surgery

 

Patient compliance with medical recommendations and monitoring of the cardiovascular system parameters after discharge from the hospital are important in the postoperative period.

Material and methods

The program of remote home monitoring of patients after cardiac surgery was created and is used in clinical practice of the department of surgical treatment of interactive pathology. First of all, we analyzed the capabilities of apps for mobile phones, ECG monitoring devices, and blood pressure monitors with the ability to remotely reset data via Bluetooth which are available in Russia. In accordance with the requirements of the high-tech clinic, the following applications were selected: MediSafe (control of drug therapy), MedMBP (control of blood pressure), Ritmer (ECG monitoring), MiFit (a step tracker). In the follow-up program 25 patients (15 men, 10 women) were included. The average age is 59±11 years (min-29, max-91). Performed interventions: 7 patients underwent RFA, 6-valve replacement with a mechanical prosthesis, 2-valve replacement with a bioprosthesis, 7-CABG, 5-PCI. The patients gave their voluntary consent to participation, confirmed their readiness and ability to use apps and devices. The initial psychological status and the quality of life were assessed using the SF 36 and HADS questionnaires. All patients were given a tonometer for BP measuring, an ECG device and a step tracker to evaluate physical activity. According to the protocol, patients measure BP and ECG daily or additionally if they feel worse; using the mobile app, they note the taken medications. All data are sent to the server and analysis by the doctor. The doctor reviews the received indicators every day and, if necessary, contacts the patient to discuss treatment tactics.

Results

For today the follow-up period is 3 months. During this period, 96% of patients strictly follow the program protocol. One patient has difficulties when using the ECG recorder, does not regularly follow the recommendations for drug therapy, which requires an individual approach. Based on the monitoring results, correction of antihypertensive therapy was necessary in 40% of cases, antiarrhythmic therapy-in 20%. In one case, a sinus node weakness syndrome was detected, and the patient was called to the hospital for the pacemaker implantation.

Conclusion

The remote monitoring program is an effective and promising tool for monitoring patients after discharge from the hospital. It is clear that the results obtained from more patients and after a longer follow-up period would be more informative. However, the intermediate initial result indicates the necessity and effectiveness of this program.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Non-invasive evaluation of the kinematic activity of the intact left ventricle of the heart

Vector analysis of the movement of the epicardium has been used to calculate the energy efficiency of different parts of the left cardiac ventricle. The protocol based on the results of these calculations would allow the calculation of the potential power of myocardial contraction.