Benefit and Risk of Prolonged Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Drug-Eluting Stents in Patients With Elevated Lipoprotein(a) Concentrations

Background: Lipoprotein(a) is positively related to cardiovascular events in patients with coronary artery disease (CAD). Given that lipoprotein(a) has a prothrombotic effect, prolonged dual antiplatelet therapy (DAPT) might have a beneficial effect on reducing ischemic events in patients with elevated lipoprotein(a) levels after percutaneous coronary intervention (PCI). We performed this study to assess the efficacy and safety of prolonged DAPT (>1 year) in this population.Methods: We evaluated a total of 3,025 CAD patients with elevated lipoprotein(a) levels who were event-free at 1 year after PCI from the prospective Fuwai PCI Registry, of which 913 received DAPT ≤ 1 year and 2,112 received DAPT>1 year. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of all-cause death, myocardial infarction or stroke.Results: After a median follow-up of 2.4 years, patients who received DAPT>1 year were associated with lower risks of MACCE compared with DAPT ≤ 1 year (1.6 vs. 3.8%; hazard ratio [HR] 0.383, 95% confidence interval [CI] 0.238–0.616), which was primarily driven by the lower all-cause mortality (0.2 vs. 2.3%; HR 0.078, 95% CI 0.027–0.227). In addition, DAPT>1 year was also associated with lower risks of cardiac death, and definite/probable stent thrombosis than those who received DAPT ≤ 1 year (P < 0.05). Conversely, no difference was found between the two groups in terms of clinically relevant bleeding. Similar results were observed in multivariate Cox regression analysis and inverse probability of treatment weighting analysis.Conclusions: In patients with elevated lipoprotein(a) concentrations after PCI, prolonged DAPT (>1 year) reduced ischemic cardiovascular events, including MACCE, all-cause mortality, cardiac mortality, and definite/probable stent thrombosis, without increase in clinically relevant bleeding risk compared with ≤ 1-year DAPT. Lipoprotein(a) levels might be a new important consideration when deciding the duration of DAPT after PCI.

Preventing Ischemic Cerebrovascular Events in High-Risk Patients With Non-disabling Ischemic Cerebrovascular Events Using Remote Ischemic Conditioning: A Single-Arm Study

Background: Secondary stroke prevention after a high-risk, non-disabling ischemic cerebrovascular event needs to be enhanced. The study was conducted to investigate whether remote ischemic conditioning (RIC) is effective in preventing recurrent ischemic events within 3 months.Methods: This was a four-center, single-arm, open-label Phase IIa futility trial (PICNIC-One Study). Adult patients (≥18 years of age) who had an acute minor ischemic stroke (AMIS) with a National Institutes of Health Stroke Scale score ≤ 3 or a transient ischemic attack (TIA) with moderate-to-high risk of stroke recurrence (ABCD score ≥ 4) within 14 days of symptom onset were recruited. Patients received RIC as adjunctive therapy to routine secondary stroke prevention regimen. RIC consisted of five cycles of 5-min inflation (200 mmHg) and 5-min deflation of cuffs (45 min) on bilateral upper limbs twice a day for 90 days.Results: A total of 285 patients met the study criteria, of which 167 provided signed informed consent and were enrolled. Data from 162 were analyzed with five subjects excluded. Recurrent AIS/TIA occurred in 6/162 (3.7%) patients within 3 months, with no occurrence of hemorrhagic stroke. The top three adverse events were upper limb pain (44/162, 27.2%), petechia (26/162, 16.0%), and heart palpitation (5/162, 3.1%). About 68 (42.0%) subjects completed ≥ 50% of 45-min RIC sessions.Conclusions: RIC is a safe add-on procedure and it has a potential benefit in reducing recurrent cerebrovascular events in patients with high-risk, non-disabling ischemic cerebrovascular events as the risk of stroke/TIA events is lower than expected; however, its compliance needs to be improved. Our study provides critical preliminary data to plan a large sample size, randomized controlled clinical study to systematically investigate the safety and efficacy of RIC in this population.

Transapical cannulation for surgical repair of chronic type B aortic dissection

Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.

Circulating Brain-Derived Neurotrophic Factor as a potential biomarker in stroke: a Systematic review and Meta-analysis

Background Stroke, an acute cerebrovascular event, is a leading cause of disability, placing a significant psycho-socioeconomic burden worldwide. Neuroplasticity is adaptation and reorganization following neuronal damage. Brain-derived neurotrophic factor (BDNF) is a neurotrophin coordinating neuroplasticity after various neurological disorders such as stroke. Methods We conducted a systematic search in the main electronic medical databases through January 2021 and identified studies that measured blood levels of BDNF in patients with stroke. The primary aim was to compare BDNF levels between patients with stroke and healthy controls (HC). The secondary aims included investigation of (1) longitudinal changes in the BDNF levels post-stroke, (2) effects of physical training, (3) repeated transcranial magnetic stimulation (rTMS), and presence of depression on BDNF levels in patients with stroke. Results Among 6243 reviewed records from PubMed, Web of Science, and Scopus, 62 studies were eligible for inclusion. Subjects with stroke, n = 1856, showed lower BDNF levels compared to HC, n=1191 (SMD [95%CI] = -1.04 [-1.49 to -0.58]). No significant difference was detected in the level of BDNF through time points past stroke. BDNF levels were lower in the patients with depression compared to non-depressed subjects (SMD [95%CI] = -0.60 [-1.10 to -0.10]). Physical training had an immediate positive effect on the BDNF levels and not statistically significant effect in the long term; SMD [95%CI] = 0.49 [0.09 to 0.88]) and SMD [95%CI] = 0.02 [-0.43 to 0.47]). Lastly, rTMS showed no effect on the level of BDNF with 0.00 SMD. Conclusions This study confirms that stroke significantly affects the level of BDNF in various domains such as cognition, affect, and motor function. We believe that BDNF could be regarded as a valuable diagnostic biomarker for acute stroke and a potential prognostic biomarker for depression and cognitive deficits.

Predictive Roles of Right Coronary Artery Disease Severity and Systemic Immune Inflammation Index in Predicting Atrial Fibrillation After Coronary Bypass Operations in Patients with Right Coronary Artery Disease

Background: Postoperative atrial fibrillation (PoAF) is observed at a rate of 25-40% in the postoperative period after coronary artery bypass graft (CABG) surgery and can increase mortality, morbidity, and treatment costs. Inflammation and coronary artery disease (CAD) severity are important parameters to predict PoAF. Methods: Patients with right coronary artery (RCA) disease who underwent isolated CABG operation between January 1, 2017 and April 15, 2020, were included in the study retrospectively. Demographic features, preoperative total Gensini score (TGS), right coronary Gensini score (RCGS), systemic immune inflammation index (SII), and postoperative characteristics were recorded. Results: A total of 283 patients were included in the study. Those who did not develop PoAF were included in Group 1 (N = 211, median age=60 (33-82) years), and those who did were included in Group 2 (N = 72, median age=68 (42-85) years). There were no statistically significant differences between the two groups, in terms of gender, hypercholesterolemia, cerebrovascular event/trans-ischemic attack history, body mass index, diabetes mellitus, smoking, beta blocker/angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, ejection fraction and left atrium diameters. As a result of multivariate analysis, advanced age (OR: 2.816 CI 95%: 1.687-3.498 P < .001), hypertension (OR:0.896, CI 95%: 0.578-0.965, P = .022), SII (OR: 1.548 CI 95%: 1.265-2.896, P = .003), TGS (OR: 1.235, CI 95%: 1.096-2.424, P = .012), and RCGS (OR: 2.112, CI 95%: 1.665-4.156, P < .001) values were determined as independent predictors for predicting postoperative atrial fibrillation. Conclusion: In this study, we showed that RCGS and SII values were independent predictors of PoAF after CABG operations in patients with right coronary artery disease.

Is It Reasonable to Perform Isolated SAVR by Residents in the TAVI Era?

Background The role of conventional surgical aortic valve replacement (SAVR) is increasingly questioned since the indication for transcatheter aortic valve implantations (TAVIs) is currently extended. While the number of patients referred to SAVR decreases, it is unclear if SAVR should be performed by junior resident surgeons in the course of a heart surgeons training. Methods Patients with isolated aortic valve replacement (AVR) were analyzed with respect to the surgeon's qualification. AVR performed by resident surgeons was compared with AVR by senior surgeons. The collective was analyzed with respect to clinical short-term outcomes comparing full sternotomy (FS) with minimally invasive surgery and ministernotomy (MS) with right anterior thoracotomy (RAT) after a 1:1 propensity score matching. Results The 30-day all-cause mortality was 2.3 and 3.4% for resident versus senior AVR groups, cerebrovascular event rates were 1.1 versus 2.6%, and no cases of significant paravalvular leak were detected. Clinical short-term outcomes between FS and minimally invasive access, as well after MS and RAT were comparable. Conclusion Our current data show feasibility and safety of conventional SAVR procedure performed by resident surgeons in the era of TAVI. Minimally invasive surgery should be trained and performed in higher volumes early in the educational process as it is a safe treatment option.

Cardiac and Other Presentation and Clinical Outcomes of COVID-19 Pandemic among Different Ethnic and Religious Populations in The City of Jerusalem

Background: The COVID‑19 pandemic is an ongoing global pandemic. Jerusalem with its 919,400 inhabitants has a wide variety of populations, of which 62% are Jews (36% ultra-orthodox; 64% non-ultraorthodox) and 38% Arabs which were largely affected by the pandemic. The aim of our study was to understand the different presentations, course and clinical outcomes in these different ethnical and cultural groups in Jerusalem in the COVID-19 pandemic. Methods: We performed a cohort study of all COVID-19 patients admitted between March 9 - July 16, 2020 to the two university medical centers in Jerusalem. Patients were divided according to their religion and ethnicity into 3 main groups: 1) Ultra-Orthodox Jews; 2) other (non-Ultra-Orthodox) Jews and 3) Arabs. Results: Six hundred and two patients comprised the study population. Of them the 361 (60%) were Ultra-Orthodox Jews; 166 (27.5%) non-Ultra-Orthodox Jews and 75 (12.5%) Arabs. The Arab patients were younger than the Ultra-Orthodox Jews and the non-Ultra-Orthodox Jews (51±18 year-old vs. 57±21 and 59±19, respectively, p<0.01), but suffered from significantly more co-morbidities. Moreover, hemodynamic shock, ischemic ECG changes and pathological chest x-ray were all more frequent in the Ultra-Orthodox patients as compared the other groups of patients. Being an Ultra-Orthodox was independently associated with significantly higher rate of Major Adverse Cardiovascular Events (MACE) [OR=1.96; 95% CI (1.03-3.71), p<0.05]. Age was the only independent risk factor associated with increased mortality rate [OR=1.10; 95% CI (1.07 - 1.13), p<0.001]. Conclusions: The COVID-19 first phase in Jerusalem, affected different ethnical and cultural groups differently, with the Ultra-Orthodox Jews mostly affected by admission rates, presenting symptoms clinical course and MACE (Acute coronary syndrome, shock, cerebrovascular event or venous thromboembolism). It is conceivable that vulnerable populations need special attention and health planning in time of pandemic, to prevent rapid distribution and severe morbidity.

Choice of Frontline Tyrosine-Kinase Inhibitor in Very Elderly Patients with Chronic Myeloid Leukemia: A "Campus CML" Study

Introduction Treatment of chronic phase (CP) chronic myeloid leukemia (CML) with tyrosine kinase inhibitors (TKIs) proved to be almost equally effective in young and elderly patients. Three TKIs, imatinib (IM), dasatinib (DAS) and nilotinib (NIL), are approved for frontline therapy in Italy. Choice of frontline TKI is based on a combined evaluation of patient's characteristics and expectations, with age usually playing a prominent role. However, to date, few data are available on patterns of TKI selection in very elderly patients. Aim To analyse the use of frontline TKI therapy in a large and unselected cohort of very elderly CP-CML patients Methods We retrospectively evaluated 332 patients aged ≥75 year diagnosed from 1/2012 to 12/2019 at 36 Hematology Centres participating at the "Campus CML" project. Results Clinical features at diagnosis for the whole cohort and according to frontline TKI are reported in Table 1. As to frontline TKI, 285 patients (85.8%) received IM and 47 (14.2%) a 2G-TKI (DAS n=28, 59.5%; NIL n=19, 40.5%). Of the 285 IM-treated patients, 192 (67.3%) started with standard dose (400 mg/day) and 93 (32.7%) with a reduced dose (300 mg/day n=64, 22.5%; &lt;300 mg/day n=29, 10.2%). Among the 47 patients starting a 2G-TKIs, 35 (74.4%) received standard dose and 12 (25.6%) a reduced dose (NIL &lt;600 mg/day n=3; DAS 80 mg/day n=4 and 50 mg/day n=5). There were no differences between patients treated with imatinib or 2G-TKI (Table 1); only a previous cerebrovascular event was reported in a significantly higher rate of IM-treated patients. It is however evident that the distinct toxicity profiles of NIL and DAS had an impact on TKI choice as, for example, no patient with diabetes or ischemic heart disease received NIL. Following widespread introduction of generic IM in Italy in early 2018, patients were divided in 2 groups: among 238 patients diagnosed from 2012 to 2017, 198 (83.1%) received IM and 40 (16.9%) a 2G-TKI, while patients diagnosed in 2018-2019 were treated with IM in 87/94 (92.5%) cases and with a 2G-TKI in 7 (7.5%) cases only (p=0.028). Conclusions IM remains the frontline drug of choice in very elderly CML patients, and this trend seems to increase after the introduction of the generic formulation. However, 2G-TKI are used in a small but sizeable group of patients, without a clear correlation with baseline CML features, thus probably reflecting a physician's evaluation of patient's fitness and/or expectation. Efficacy and safety of initial reduced TKIs doses in the setting of very elderly patients warrant further analyses. Figure 1 Figure 1. Disclosures Latagliata: Novartis: Honoraria; BMS Cellgene: Honoraria; Pfizer: Honoraria. Bonifacio: Novartis: Honoraria; Pfizer: Honoraria; Amgen: Honoraria; Bristol Myers Squibb: Honoraria. Elena: CELGENE: Other: funding for meeting participation; PFIZER: Membership on an entity's Board of Directors or advisory committees; NOVARTIS: Membership on an entity's Board of Directors or advisory committees; GILEAD: Membership on an entity's Board of Directors or advisory committees. Iurlo: Novartis: Speakers Bureau; Incyte: Speakers Bureau; Pfizer: Speakers Bureau; Bristol Myers Squibb: Speakers Bureau. Sportoletti: AstraZeneca: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria. Stagno: Pfizer: Consultancy, Honoraria, Other: Support for attending meetings and/or travel; InCyte: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Other: Support for attending meetings and/or travel, Research Funding. Abruzzese: Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria. Breccia: Bristol Myers Squibb/Celgene: Honoraria; Incyte: Honoraria; Abbvie: Honoraria; Pfizer: Honoraria; Novartis: Honoraria.

Assessment of the frequency and possible risk factors for paroxysmal atrial fibrillation in the early postoperative period after transapical implantation of the MedLab-CT valve

Aim. To study the incidence and possible risk factors for atrial fibrillation (AF) in the early postoperative period after transapical implantation of the first Russian aortic valve (TAP-AVI).Methods. The study included 118 patients after successful TAP-AVI. Patients with open aortic valve replacement due to dislocation of the prosthesis were excluded, as well as subjects with permanent AF and who died in the early postoperative period. The mean age of the patients was 71.1±4.9 years, body mass index 31.1±5.9 kg/m2 , males - 39.8%, hypertension was present in 93.2%, diabetes mellitus (DM) - in 27.9%, paroxysmal AF - in 12.7%, coronary artery disease (CAD) was in 56.7%, 8.4% were smokers. The median follow-up time corresponded to the hospital stay - 9.5 days. To identify cardiac arrhythmias, regular daily ECG recording in 12 leads was initiated from the first day after TAP-AVI. In the presence of palpitations, 24-hour ECG monitoring was performed. Indicators such as age, male gender, DM, history of AF, interatrial block before surgery, CAD, and echocardiographic parameters were studied as possible predictors of AF development in the early postoperative period after TAP-AVI. There were no significant differences in the baseline parameters in patients with AF paroxysms and sinus rhythm.Results. In the early postoperative period, AF was encountered in 46 (39%) of patients. New-onset AF occurred in 38 (32.2%) patients. No cerebrovascular event occurred in patients with post-surgery AF. The only statistically significant risk factor for AF in the postoperative period was CAD (OR 5.756; 95% CI 1.009-8.132; p = 0.048).Conclusion. In the early postoperative period, the only significant predictor of AF was the presence of documented CAD.

Impact of valvular heart disease on hip replacement: a retrospective nationwide inpatient sample database study

Background To study the impact of valvular heart disease (VHD) on hip replacement, particularly the clinical impactions of aortic stenosis before total/partial hip arthroplasty. Methods This was a retrospective cohort study. Data on patients who had undergone hip replacement from 2005 to 2014 were extracted from the NIS database. Independent t test and chi-square test were used to analyze the essential characteristics of patients. Multivariate regression was used to estimate the correlation among demographics, comorbidities, complications, hospitalization costs, and time. Results VHD accounted for 5.56% and AS accounted for 0.03% of the patients before hip replacement surgeries. Patients with VHD before hip replacement are related to the following characteristics: female patients (odds ratio [OR] = 1.15 [1.12–1.18]), elective admission (OR = 0.78 [0.76–0.80]), Charlson Comorbidity Index ≥3 (OR = 1.06 [1.03–1.08]), large-volume hospitals (OR = 1.13 [1.1–1.2]), teaching hospitals (OR = 5 4.4 [2.9–6.7]), and hospital location in urban areas (OR = 1.22 [1.2–1.3]). In addition, VHD is a risk factor for mortality and some acute postoperative medical complications, such as acute cardiac event (OR = 2.96 [2.87–3.04]), acute pulmonary edema (OR = 1.13 [1.06–1.21]), acute cerebrovascular event (OR = 1.22 [1.16–1.74]), and acute renal failure (OR = 1.22 [1.17–1.27]). It also has an impact on DVT/PE (OR = 0.89 [0.8–0.99]). Patients with AS before hip replacement have basic demographic characteristics like those of hip replacement patients with valvular disease. Patients with AS are older than those without AS before surgery (OR = 3.28 [2.27–4.75) and are related to the following characteristics: female patients (OR = 1.92 [1.32–2.8]) and elective admission (OR = 0.51 [0.36–0.75]). The perioperative period is limited to acute postoperative complications, such as acute cardiac events (OR = 2.50 [1.76–3.53]) and acute hepatic failure (OR = 7.69 [1.8–32.89]). Both valvular diseases and AS are associated with a higher mortality rate and hospitalization cost. Conclusion VHD independently predicted mortality rate and surgical and medical complications after total/partial hip arthroplasty.