Antithrombotic therapy for atrial fibrillation and comorbidities — how to choose the optimal solution?

The review discusses the problem of anticoagulant therapy for the prevention of stroke and systemic embolism in patients with atrial fibrillation and comorbidities (hypertension, heart defects, including after heart valve surgery, coronary artery disease, diabetes mellitus, chronic kidney disease, gastrointestinal diseases, anemia, cancer), as well as with a high risk of emergency operations and injuries.

Determining Factors for Independent Walking in Patients Undergoing Cardiovascular Surgery: Differences between Coronary Artery Bypass Grafting, Heart Valve Surgery, and Aortic Surgery

Physical deconditioning often occurs during the acute phase after cardiovascular surgery, and unassisted walking is required to achieve independence, to manage cardiac diseases, and to prevent recurrences. This study aims to investigate the characteristics of independent walking after cardiovascular surgery. We conducted a retrospective cohort study in patients who underwent cardiovascular surgeries (total of 567 patients): 153 in the coronary artery bypass grafting (CABG) group, 312 in the heart valve surgery group, and 102 in the aortic surgery group. We evaluated the effect of each surgery group on the cardiac rehabilitation (CR) progression. The factors associated with independent walking were age, renal diseases, intensive care unit (ICU) length of stay, and post-operative respiratory complications in the CABG group. In the heart valve surgery group, the factors were New York Heart Association functional classification, renal and respiratory diseases, ICU length of stay, duration of mechanical ventilatory support, and post-operative cardiovascular and respiratory complications. In the aortic surgery group, these were ICU length of stay and acute kidney injury. The CR progression in patients who underwent aortic surgery was significantly longer than those who underwent CABG and heart valve surgery (p < 0.001). New intervention strategies are needed for patients with prolonged ICU stays.

Limb Remote Ischemic Preconditioning Applied During Sevoflurane Anesthesia Does Not Protect the Lungs in Patients Undergoing Adult Heart Valve Surgery

Background: Two consistent overall cell protective preconditioning treatments should provide more protection. We hypothesized that limb remote ischemic preconditioning (RIPC, second preconditioning stimulus) applied during sevoflurane inhalation (first preconditioning stimulus) would provide more protection to the lungs of patients undergoing adult heart valve surgery. Methods: In this randomized, placebo-controlled, double-blind trial, 50 patients were assigned to the RIPC group or the placebo group (1:1). Patients in the RIPC group received three 5-min cycles of 300 mmHg cuff inflation/deflation of the left-side lower limb before aortic cross-clamping. Anesthesia consisted of opioids and propofol for induction and sevoflurane for maintenance. The primary end point was comparison of the postoperative arterial–alveolar oxygen tension ratio (a/A ratio) between groups. Secondary end points included comparisons of pulmonary variables, postoperative morbidity and mortality and regional and systemic inflammatory cytokines between groups. Results: In the RIPC group, the a/A ratio and other pulmonary variables exhibited no significant differences throughout the study period compared with the placebo group. No significant differences in either plasma or bronchoalveolar lavage levels of TNF- α were noted between the groups at 10 min after anesthetic induction and 1 h after cross-clamp release. The percentage of neutrophils at 12 h postoperation was significantly increased in the RIPC group compared with the placebo group (91.34±0.00 vs. 89.42±0.10, P = 0.023). Conclusions: Limb RIPC applied during sevoflurane anesthesia did not provide additional significant pulmonary protection following adult valvular cardiac surgery.

The multivariable prognostic models for severe complications after heart valve surgery

Background To provide multivariable prognostic models for severe complications prediction after heart valve surgery, including low cardiac output syndrome (LCOS), acute kidney injury requiring hemodialysis (AKI-rH) and multiple organ dysfunction syndrome (MODS). Methods We developed multivariate logistic regression models to predict severe complications after heart valve surgery using 930 patients collected retrospectively from the first affiliated hospital of Sun Yat-Sen University from January 2014 to December 2015. The validation was conducted using a retrospective dataset of 713 patients from the same hospital from January 2016 to March 2017. We considered two kinds of prognostic models: the PRF models which were built by using the preoperative risk factors only, and the PIRF models which were built by using both of the preoperative and intraoperative risk factors. The least absolute shrinkage selector operator was used for developing the models. We assessed and compared the discriminative abilities for both of the PRF and PIRF models via the receiver operating characteristic (ROC) curve. Results Compared with the PRF models, the PIRF modes selected additional intraoperative factors, such as auxiliary cardiopulmonary bypass time and combined tricuspid valve replacement. Area under the ROC curves (AUCs) of PRF models for predicting LCOS, AKI-rH and MODS are 0.565 (0.466, 0.664), 0.688 (0.62, 0.757) and 0.657 (0.563, 0.751), respectively. As a comparison, the AUCs of the PIRF models for predicting LOCS, AKI-rH and MODS are 0.821 (0.747, 0.896), 0.78 (0.717, 0.843) and 0.774 (0.7, 0.847), respectively. Conclusions Adding the intraoperative factors can increase the predictive power of the prognostic models for severe complications prediction after heart valve surgery.

Clinical Significance and Prognostic Factors of Simultaneous Heart Valve Surgery and Coronary Artery Bypass Grafting in Treating Patients with Valvular Heart Disease Complicated by Coronary Heart Disease

This study was designed to evaluate the clinical significance of simultaneous heart valve surgery and coronary artery bypass grafting for patients with valvular heart disease complicated by coronary heart disease and its influence on their prognosis. A total of 121 patients with valvular heart disease complicated by coronary heart disease who were surgically treated in our hospital from January 2013 to March 2017 were selected. The observation group (OG) (64 patients) underwent simultaneous valvular heart surgery and coronary artery bypass grafting. The control group (CG) (57 patients) underwent non-synchronous heart valve surgery and coronary artery bypass grafting. The operation, hospitalization, occurrence of adverse events and changes of cardiac function indexes of patients from the two groups were compared, and the factors affecting their prognosis were confirmed in multivariate analysis. The ventilator application time, postoperative ICU monitoring time, postoperative general ward time and total incidence of adverse events in the OG were lower than those in the CG (P<0.05). After treatment, the cardiothoracic ratio, left ventricular end-diastolic volume and BNP content in the two groups were markedly higher than before treatment, and the increase in the OG was more obvious (P<0.05); the left ventricular ejection fraction in both groups was markedly lower than that before treatment (P<0.05), and the decrease in the OG was more obvious (P<0.05). Multivariate analysis showed that hypertension, treatment methods, course of disease and age were independent risk factors affecting the prognosis of patients with valvular heart disease complicated by coronary heart disease. Simultaneous heart valve surgery and coronary artery bypass grafting can reduce the occurrence of adverse events and improve cardiac function indexes, which is worthy of clinical application. Hypertension, treatment methods, course of disease and age are independent risk factors affecting the prognosis of those patients.

Early Outcomes in Patients with Severe Dilated Left Ventricle Disease after Heart Valve Surgery

Objectives: The study sought to examine the prognostic impact of valvular surgery in patients with severe dilated left ventricle(DL) and assess morphological and functional changes of DL in the early period after operation. Methods: From January 2013 to December 2018, at a single center, 126 patients with severe dilated left ventricle (DL group) and 511 patients with 511 patients with normal sized left ventricle (NL group) underwent heart valve surgery. Retrospective review of the procedure and the postoperative clinical course, including echocardiography were analyzed in 6 to 12-month follow up. Results: Compared with NL group, DL group had significantly higher postoperative all-cause mortality (3.2% vs 1.4%) and complication rate, as well as longer duration of mechanical ventilation and vasoactive agents support. In DL group, 4 (3.2%) patients died in the early postoperative stage among which 2 (1.6%) patients died from multiple organ failure (MOF) secondary to severe low-output syndrome, 2 (1.6%) patients died from ventricular fibrillation. The DL group had longer time of mechanical ventilation and vasoactive agents support than NL group postoperatively. In DL group, the progressive regression of end-diastole diameter (LVEDD) was observed during the follow-up; whereas left ventricular ejection function (LVEF) and left ventricular fractional shortening (LVFS) showed a temporary decrease in early postoperative stage and then improved gradually. Conclusion: Heart valve surgery performed in an experienced center, along with sophisticated perioperative management, could bring satisfying early outcomes to patients with severe dilated left ventricle.