New Anticoagulants in Cardiac Surgery

2011 ◽  
Vol 6 (1) ◽  
pp. 71 ◽  
Author(s):  
Stuart J Head ◽  
Ad JJC Bogers ◽  
A Pieter Kappetein ◽  
◽  
◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Heart Valve ◽  
Heart Surgery ◽  
Artery Bypass ◽  
Vitamin K Antagonists ◽  
Dabigatran Etexilate ◽  
Oral Anticoagulants ◽  
Mechanical Heart Valve ◽  
Ease Of Use ◽  
Risk Of Bleeding

Antiplatelet and anticoagulant therapy is a key part of the management of patients undergoing cardiac surgery and one of the cornerstones to prevent complications after coronary bypass or valvular heart surgery. The use of anticoagulants and antiplatelets is life-saving, but these agents also contribute to the risk of bleeding. The only orally active anticoagulants that are licensed for long-term use are vitamin K antagonists (VKAs), such as warfarin and are often prescribed after mechanical heart valve implantation or in case of atrial fibrillation. Bleeding is a significant adverse event. Another major drawback of warfarin is the need for routine coagulation monitoring and even with monitoring, the international normalised ratio is frequently outside the therapeutic range. Development of new antithrombotic drugs has been targeted to improve the clinical benefit by reducing bleeding and thromboembolic complications and improving the ease of use. The many limitations of VKAs have provoked the development of new oral anticoagulants. Recently, dabigatran etexilate and ticagrelor have been introduced as possible substitutes. Furthermore, agents are evaluated to treat patients with acute coronary syndromes. Clopidogrel is often used, but this increases the risk of bleeding in patients in which coronary artery bypass grafting is necessary. This review outlines the alternatives of warfarin and clopidogrel therapy for patients with a mechanical heart valve or who undergo bypass surgery. It also establishes a five-year view for key contenders to replace the existing standard therapy.

Perioperative management of the high-risk surgical patient: cardiac surgery

2021 ◽  
pp. 1009-1024
Author(s):  
Marco Ranucci ◽  
Serenella Castelvecchio ◽  
Andrea Ballotta
Keyword(s):  
Cardiac Surgery ◽  
High Risk ◽  
Heart Surgery ◽  
Artery Bypass ◽  
Oral Anticoagulants ◽  
Treatment Options ◽  
Bypass Graft ◽  
High Risk Patient ◽  
Advanced Age ◽  
Surgical Patient

During the last decade, as a result of continually improving surgical strategy and the technology which supports it (e.g. anaesthesia), cardiac surgery is offered to patients with advanced age and those with increasingly complex co-existing conditions that were previously considered to be contraindications. In addition, an increasing number of patients have previously undergone angioplasty, thereby delaying their initial coronary artery bypass graft surgery to a more advanced age. In general, candidates for cardiac surgery may now be not only older than in the past, but also more likely to have health problems such as hypertension and diabetes. Risk stratification may help to identify 'the' high-risk patient: 'pre-warned is pre-armed'. In high-risk cardiac surgery patients, the surgical treatment options and perioperative care must be tailored to each patient, in order to optimize the benefits and minimize the risk of detrimental effects. The preoperative anticoagulation practice is an important aspect, balancing the risk between ischaemic and bleeding complications. New antiplatelet agents and oral anticoagulants have been recently delivered, and their role in patients scheduled for heart surgery is an additional important issue.

scholarly journals Low Level of Knowledge of Atrial Fibrillation and Anticoagulant Treatment among Patients with Atrial Fibrillation Scheduled for Cardiac Surgery

2020 ◽  
pp. 1-7
Author(s):  
Anetta Undas ◽  
Aleksandra Lipska ◽  
Anetta Undas ◽  
Hein Heidbuchel ◽  
Jacek Legutko ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cardiac Surgery ◽  
Artery Bypass ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Bypass Graft ◽  
Control Group ◽  
Safety Issues ◽  
Valvular Surgery ◽  
Level Of Knowledge

Objective: We investigated the knowledge about atrial fibrillation (AF) and oral anticoagulants (OACs) in AF patients scheduled for cardiac surgery compared with nonsurgical AF patients. Methods: We recruited 144 consecutive patients with documented AF scheduled for cardiac surgery on admission (aged 68.9±8.4, male 60.4 %). The control group represented 200 age- and sex-matched AF patients without indications for surgery. Using the validated Jessa AF Knowledge Questionnaire (JAKQ), we tested their knowledge of AF and the use of OAC. Results: The mean score on the JAKQ was 47±20 % in the surgery group and 59±18 % in the control group (p<0.001), without any questions in which the former group scored better. A higher level of knowledge was observed in patients taking vitamin K antagonists (VKA) in the past, and individuals free of heart failure, previous stroke, or peripheral artery disease. Patients had poor knowledge of the safety issues, including 27.5% of surgical patients who knew about possible painkillers use during anticoagulation compared with 43.8% in the control group (p=0.002). Patients scheduled for valvular surgery (n=88, 61.5%) scored better compared with those (n=26, 18.2%) for coronary artery bypass graft (CABG) surgery (49±19% vs. 35±18 %, p=0.002 respectively). Conclusion: The level of knowledge about AF and its treatment, including the safety issues, is poor among AF patients admitted for cardiac surgery. More educational efforts should be taken in this vulnerable patient subset.

A Comparison of a Moderate with Moderate-high Intensity Oral Anticoagulant Treatment in Patients with Mechanical Heart Valve Prostheses

1997 ◽  
Vol 77 (05) ◽  
pp. 0839-0844 ◽  
Author(s):  
Vittorio Pengo ◽  
Fabio Barbero ◽  
Alberto Banzato ◽  
Elisabetta Garelli ◽  
Franco Noventa ◽  
...  
Keyword(s):  
Heart Valve ◽  
High Intensity ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Mechanical Heart Valve ◽  
Moderate Intensity ◽  
Minor Bleeding ◽  
Anticoagulant Treatment ◽  
Oral Anticoagulant Treatment ◽  
Valve Prostheses

SummaryBackground. The long-term administration of oral anticoagulants to patients with mechanical heart valve prostheses is generally accepted. However, the appropriate intensity of oral anticoagulant treatment in these patients is still controversial.Methods and Results. From March 1991 to March 1994, patients referred to the Padova Thrombosis Center who had undergone mechanical heart valve substitution at least 6 months earlier were randomly assigned to receive oral anticoagulants at moderate intensity (target INR = 3) or moderate-high intensity (target INR = 4). Principal end points were major bleeding, thromboembolism and vascular death. Minor bleeding was a secondary end-point.A total of 104 patients were assigned to the target 3 group and 101 to the target 4 group; they were followed for from 1.5 years to up 4.5 years (mean, 3 years). Principal end-points occurred in 13 patients in the target 3 group (4 per 100 patient-years) and in 20 patients in the target 4 group (6.9 per 100 patient-years). Major hemorrhagic events occurred in 15 patients, 4 in the target 3 group (1.2 per 100 patient-years) and 11 in the target 4 group (3.8 per 100 patient-years) (p = 0.019). The 12 recorded episodes of thromboembolism, 4 of which consisted of a visual deficit, were all transient ischemic attacks, 6 in the target 3 group (1.8 per 100 patient-years) and 6 in the target 4 group (2.1 per 100 patient- years). There were 3 vascular deaths in each group (0.9 and 1 per 100 patient-years for target 3 and target 4 groups, respectively). Minor bleeding episodes occurred 85 times (26 per 100 patient-years) in the target 3 group and 123 times (43 per 100 patient-years) in the target 4 group (p = 0.001).Conclusions. Mechanical heart valve patients on anticoagulant treatment who had been operated on at least 6 months earlier experienced fewer bleeding complications when maintained on a moderate intensity regimen (target INR = 3) than those on a moderate-high intensity regimen (target INR = 4). The number of thromboembolic events and vascular deaths did not differ between the two groups.

The Use of Posterior Pericardiotomy Technique to Prevent Postoperative Pericardial Effusion in Cardiac Surgery

2012 ◽  
Vol 15 (2) ◽  
pp. 84 ◽  
Author(s):  
Canturk Cakalagaoglu ◽  
Cengiz Koksal ◽  
Ayse Baysal ◽  
Gokhan Alici ◽  
Birol Ozkan ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Heart Surgery ◽  
Artery Bypass ◽  
Pericardial Tamponade ◽  
Anxiety Level ◽  
Control Group ◽  
Echocardiographic Study ◽  
Number Of Patients ◽  
Hospital Stays

<p><b>Aim:</b> The goal was to determine the effectiveness of the posterior pericardiotomy technique in preventing the development of early and late pericardial effusions (PEs) and to determine the role of anxiety level for the detection of late pericardial tamponade (PT).</p><p><b>Materials and Methods:</b> We divided 100 patients randomly into 2 groups, the posterior pericardiotomy group (n = 50) and the control group (n = 50). All patients undergoing coronary artery bypass grafting surgery (CABG), valvular heart surgery, or combined valvular and CABG surgeries were included. The posterior pericardiotomy technique was performed in the first group of 50 patients. Evaluations completed preoperatively, postoperatively on day 1, before discharge, and on postoperative days 5 and 30 included electrocardiographic study, chest radiography, echocardiographic study, and evaluation of the patient's anxiety level. Postoperative causes of morbidity and durations of intensive care unit and hospital stays were recorded.</p><p><b>Results:</b> The 2 groups were not significantly different with respect to demographic and operative data (<i>P</i> > .05). Echocardiography evaluations revealed no significant differences between the groups preoperatively; however, before discharge the control group had a significantly higher number of patients with moderate, large, and very large PEs compared with the pericardiotomy group (<i>P</i> < .01). There were 6 cases of late PT in the control group, whereas there were none in the pericardiotomy group (<i>P</i> < .05). Before discharge and on postoperative day 15, the patients in the pericardiotomy group showed significant improvement in anxiety levels (<i>P</i> = .03 and .004, respectively). No differences in postoperative complications were observed between the 2 groups.</p><p><b>Conclusion:</b> Pericardiotomy is a simple, safe, and effective method for reducing the incidence of PE and late PT after cardiac surgery. It also has the potential to provide a better quality of life.</p>

scholarly journals Update on Edoxaban for the Prevention and Treatment of Thromboembolism: Clinical Applications Based on Current Evidence

2015 ◽  
Vol 2015 ◽  
pp. 1-19 ◽  
Author(s):  
Ali Zalpour ◽  
Thein Hlaing Oo
Keyword(s):  
Vitamin K Antagonists ◽  
Dabigatran Etexilate ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Factors ◽  
Current Evidence ◽  
Thrombin Inhibitor ◽  
Prevention And Treatment ◽  
Financial Impacts

Vitamin K antagonists (VKA) and heparins have been utilized for the prevention and treatment of thromboembolism (arterial and venous) for decades. Targeting and inhibiting specific coagulation factors have led to new discoveries in the pharmacotherapy of thromboembolism management. These targeted anticoagulants are known as direct oral anticoagulants (DOACs). Two pharmacologically distinct classes of targeted agents are dabigatran etexilate (Direct Thrombin Inhibitor (DTI)) and rivaroxaban, apixaban, and edoxaban (direct oral factor Xa inhibitors (OFXaIs)). Emerging evidence from the clinical trials has shown that DOACs are noninferior to VKA or low-molecular-weight heparins in the prevention and treatment of thromboembolism. This review examines the role of edoxaban, a recently approved OFXaI, in the prevention and treatment of thromboembolism based on the available published literature. The management of edoxaban in the perioperative setting, reversibility in bleeding cases, its role in cancer patients, the relevance of drug-drug interactions, patient satisfaction, financial impacts, and patient education will be discussed.

Risk Factors and Outcomes Associated With Sepsis After Coronary Artery Bypass and Open Heart Valve Surgeries

2018 ◽  
Vol 22 (4) ◽  
pp. 359-368 ◽  
Author(s):  
Sergey Karamnov ◽  
Ethan Y. Brovman ◽  
Katherine J. Greco ◽  
Richard D. Urman
Keyword(s):  
Risk Factors ◽  
Cardiac Surgery ◽  
Coronary Artery ◽  
High Risk ◽  
Coronary Artery Bypass ◽  
Heart Valve ◽  
Artery Bypass ◽  
Open Heart ◽  
Postoperative Sepsis ◽  
Post Cardiac Surgery

Purpose. Sepsis causes significant morbidity and mortality after cardiac surgery and carries a significant burden on health care costs. There is a general association of increased risk of post–cardiac surgery sepsis in patients with postoperative complications. We sought to investigate significant patient and procedural risk factors and outcomes associated with sepsis after cardiac surgery. Materials and Methods. In this retrospective study, we analyzed 531 coronary artery bypass grafting and open heart valve surgery cases that developed postoperative sepsis in the National Surgical Quality Improvement Program database between 2007 and 2014. Patient-based and surgery-based parameters were analyzed for risk factors and outcomes reported in the 30 days postoperatively. The association between sepsis and patient outcomes was assessed in a propensity-matched cohort using univariable logistic regression. Results. Modifiable and nonmodifiable patient characteristics, including age >80, poor preoperative functional status, chronic diseases such as diabetes mellitus, congestive heart failure, chronic kidney disease with serum creatinine ⩾1.5, as well as serum albumin <3.5 and emergent nature of the case were associated with post–cardiac surgery sepsis. Surgical outcomes associated with sepsis included mortality (15.4% vs 4.5%), unplanned intubation (29.8% vs 8.2%), transfusion (53.4% vs 48.4%), acute kidney injury (7.1% vs 1.4%), postoperative dialysis (18.8% vs 3.5%), and return to the operating room (29.8% vs 8.2%). Conclusions. We identified multiple patient and surgical characteristics as well as postoperative outcomes associated with postoperative sepsis development in the high-risk population of patients undergoing cardiac surgery. Early identification of patients who are at high risk for postoperative sepsis can facilitate early treatment interventions.

Abstract 266: Incidence, Predictors and Outcomes of Permanent Pacemaker Implantation Among Patients With Bradyarrhythmias Following Cardiac Surgery: Insights From the National Inpatient Sample Database

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Karol Quelal ◽  
Olakanmi Olagoke ◽  
Jose Baez
Keyword(s):  
Cardiac Surgery ◽  
Valve Replacement ◽  
Heart Surgery ◽  
Artery Bypass ◽  
Open Heart Surgery ◽  
Pacemaker Implantation ◽  
Permanent Pacemaker ◽  
Hospital Death ◽  
National Inpatient Sample ◽  
Permanent Pacemaker Implantation

Introduction: Significant atrioventricular blocks and bradyarrhythmias are known complications of open-heart surgery. These are frequently transient, however, some patients go on to need a permanent pacemaker (PP). We sought to describe the incidence, predictors, and outcomes of PP implantation among patients admitted for cardiac surgery who develop bradyarrhythmias. Methods: We queried the National Inpatient Sample (NIS) database from 2010 to 2014 for adults admitted for surgical valve replacement, valvuloplasty or coronary artery bypass grafting (CABG) who had bradyarrhythmias during the admission using the appropriate ICD codes. We identified patients who had permanent pacemaker implantation documented during the admission. Categorical and continuous variables were compared using the chi-square and student's t-test. Predictors of PP implantation and in-hospital mortality were evaluated by logistic regression. Results: Of the 1402930 patients who underwent cardiac surgery, 94748 patients had bradyarrhythmias defined as sinoatrial node dysfunction (SND) and/or atrioventricular block (AVB) during hospitalization. The primary procedure was identified as valve replacement in 50.3% (47615 of 94748), CABG in 29.9% (27622 of 94748) and valvuloplasty in 8.7% (8248 of 94748). SND was found in 29.9% (28372 of 94748) and AVB in 76% (72017 of 94748). Permanent pacemaker implantation was done in 39.3% (37246 of 94748). Valve replacement was the most common surgery associated with PP implantation [58% (21682 of 37246) compared to 21.5% in CABG (8007 of 37246) and 7.7% in valvuloplasty (2882 of 37246), p < 0.001). Female sex aOR 1.36 (95% CI 1.31 - 1.40), young age 18 - 44 years aOR 1.36 (95% CI 1.24 - 1.49), Asiatic and Hispanic origin aOR 1.36 (95% CI 1.23 - 1.51), aOR 1.25 (95% CI 1.17 - 1.34) respectively, diabetes mellitus with chronic complications aOR 1.16 (95% CI 1.09 - 1.24), drug abuse aOR 1.38 (95% CI 1.21 - 1.55) were associated with higher odds of pacemaker implantation. African American origin aOR 0.79 (95CI 0.74 - 0.85), AIDS aOR 0.33 (95% CI 0.17 - 0.67), south hospital region aOR 0.89 (95% CI 0.85 - 0.93), no-charge admissions aOR 0.66 (95% CI 0.49 - 0.89) were associated with a lower odds of PPM implantation. Death during hospitalization was found in 3% of the patients. After multivariable regression, PP implantation was associated with a lower likelihood of in-hospital death aOR 0.45 (95% CI 0.41 - 0.50). Conclusion: Approximately one-third of the patients hospitalized for cardiac surgery related to AVB and/or SND were implanted a permanent pacemaker. Factors like age, sex, race and comorbidities determine the likelihood of this procedure that has a significant impact on mortality. Having a better insight into these predictors would allow a better triage of patients who would benefit from its implantation.

scholarly journals New Oral Anticoagulants: An Update

2019 ◽  
Vol 37 (3) ◽  
pp. 135-150
Author(s):  
Quamruddin Ahmad ◽  
Md Mahin Reza ◽  
Md Ahosan Habib ◽  
Syed Faravee Masud ◽  
Nasiruddin ◽  
...  
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Mechanical Heart Valve ◽  
The United States ◽  
Medical Intervention ◽  
New Drugs ◽  
Thrombin Inhibitor ◽  
Valve Prosthesis ◽  
Coronary Syndrome

One of the most common and useful forms of medical intervention is anticoagulant therapy and it is the mainstay of treatment and prevention of thrombosis in different clinical settings, like atrial fibrillation (AF), acute coronary syndrome (ACS), acute venous thromboembolism (VTE), and in patients undergoing invasive cardiac procedures. More than 6 million patients in the United States receive long-term anticoagulation therapy for the prevention of thromboembolism due to AF, placement of a mechanical heart-valve prosthesis, or VTE.1 For more than 60 years, until 2009, warfarin and other vitamin K antagonists were the only class of oral anticoagulants (OAC) available. Although these drugs are highly effective in prevention of TE, their use is limited by a narrow therapeutic index that necessitates frequent monitoring and dose adjustments. This results in substantial risk and inconvenience, leading to inadequate anticoagulant prophylaxis. Recently some new OAC have been marketed which are effective, easier to use and has less side effects. Dabigatran is a new oral thrombin inhibitor and Rivaroxaban, Apixaban and Edoxaban are oral factor Xa inhibitors. This review outlines why these new OACs were essential and describes in detail about these new drugs. J Bangladesh Coll Phys Surg 2019; 37(3): 135-150

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