Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Background: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a “closed space” must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption. Methods: Eighty relevant English language papers published in PubMed were reviewed in detail. Results: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement. Conclusion: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.

Can double internal thoracic artery grafts affect 10-year outcomes after coronary artery bypass grafting?

Background The advantages of the employment of double internal thoracic artery grafts (BITA) for coronary artery bypass grafting have been recently questioned and no data on long-term follow-up are available. This observational retrospective cohort study was designed by the PRIORITY planning committee to evaluate 10-year follow-up of isolated CABG performed with and without BITA in order to clarify and consolidate the contrasting literature. Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event distributions were separately analyzed accordingly to primary event-type (death, MACEs), using Kaplan-Meier estimates and Cox regression. Results The population consisted of 11021 patients who underwent isolated CABG that were divided into development and validation datasets; double thoracic internal artery grafts was employed in 24.6%. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. After adjustment for potential confounding factors, BITA was significantly associated with better survival (HR 0.85, 95% CI 0.76–0.95, p=0.003). Moreover, the employment of BITA reduced the incidence of MACEs at follow-up (adjusted HR 0.87, 95% CI 0.80–0.94, p=0.001). In details, BITA was demonstrated to be a protective factor for acute myocardial infarction (adjusted HR 0.84, 95% CI 0.71–0.99, p=0.05) and for rehospitalization for percutaneous cardiac intervention (PCI; adjusted HR 0.82, 95% CI 0.70–0.96, p=0.013). Conclusions The employment of double internal thoracic artery grafts for coronary artery bypass grafting has been associated to survival advantage at 10-year. Moreover, it significantly decreased the incidence of acute myocardial infarction and rehospitalization for percutaneous cardiac intervention. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

AN INTERVENTIONAL CARDIOLOGY INVESTIGATION: PATIENT EXPOSURE TO RADIATION AND INTER-OPERATOR VARIABILITY IN AN IRISH SETTING

Aim: To evaluate patient radiation exposure for Diagnostic Coronary Angiography (DCA) and Percutaneous Cardiac Intervention (PCI) performed by different operators. Methods and Results: Retrospective (n = 160) and prospective (n = 62) data for DCA (n = 179) and PCI (n = 43) examinations performed by interventional cardiologists (n = 3) using the same imaging equipment were reviewed. The operator with consistently low diagnostic reference levels (DRLs) was interviewed for their personal perceptions upon operator training. Retrospective Median [IQR] DAP was 18.8 [11.8–31.6] and 50.7 [35.3–85.6] Gy.cm2 for DCA and PCI, respectively. Prospective Median [IQR] DAP for DCA and PCI was 7.9 [5.2–10.6] and 15.9 [10.0–17.7] Gy.cm2, respectively. DRLs were within Irish and European DRLs; however, significant inter-operator variability (p < .001) was identified. Conclusion: Radiation exposure in Interventional cardiology is highly operator dependent; further research is warranted in standardization of operator training with evolving technologies.

Is a cardiac catheterization procedure at hospitals without on-site surgical backup safe?

<p>Percutaneous cardiac catheterization procedures have now become an established and preferable method. Initially, these procedures were performed at clinical sites with surgical backup as complication rates and need of urgent surgery were high. With the improvement in catheter technique, experienced operators and the development of new devices, overall complication rates of catheterization are low and emergency cardiac surgery has become an increasingly rare event. The aim of the study was to evaluate the procedural outcomes for cardiac interventions in a tertiary-level hospital without onsite cardiac surgery backup. This was a prospective descriptive study. All consecutive patients who were admitted for percutaneous cardiac interventions, including both diagnostic as well as therapeutic interventions, between September 2013 and August 2015 were included in this study. Total 692 percutaneous cardiac interventions were performed. The mean age was 61.9 ± 18.3 years. 439(63.52%) procedures were carried out in men. PCI was done in 189(27 .31%). Percuteneous transvenous mitral comissurotomy was done in 49(7.08%) cases, coronary angiogram was done in 395(57.08%), permanent pacemaker insertion in 29(4.20%), peripheral angiogram in 16(2.30%), pericardiocentesis in 14(2 .02%).Primary PCI was done in 62(32.88%). The most frequent indication for PCI was STEMI 106(56.16%). Complications like Post-procedural cardiogenic shock in 4 (2.11%) cases, arrhythmias and minor complications in 7 (3.70%), and death in 4 (2.11%) patients was witnessed. Similarly, periprocedural MI and contrast induced nephropathy (CIN) requiring dialysis stroke or transient ischemic attack were not noted.Cardiac tamponade was observed in 1 (2.02%) patient during PTMC. There was no need of emergency cardiac surgery Percutaneous cardiac intervention was feasible with acceptable complications in a tertiary-level hospital without onsite cardiac surgery backup.</p>

Is a cardiac catheterization procedure at hospitals without on-site surgical backup safe?

Percutaneous cardiac catheterization procedures have now become an established and preferable method. Initially, these procedures were performed at clinical sites with surgical backup as complication rates and need of urgent surgery were high. With the improvement in catheter technique, experienced operators and the development of new devices, overall complication rates of catheterization are low and emergency cardiac surgery has become an increasingly rare event. The aim of the study was to evaluate the procedural outcomes for cardiac interventions in a tertiary-level hospital without onsite cardiac surgery backup. This was a prospective descriptive study. All consecutive patients who were admitted for percutaneous cardiac interventions, including both diagnostic as well as therapeutic interventions, between September 2013 and August 2015 were included in this study. Total 692 percutaneous cardiac interventions were performed. The mean age was 61.9 ± 18.3 years. 439(63.52%) procedures were carried out in men. PCI was done in 189(27 .31%). Percuteneous transvenous mitral comissurotomy was done in 49(7.08%) cases, coronary angiogram was done in 395(57.08%), permanent pacemaker insertion in 29(4.20%), peripheral angiogram in 16(2.30%), pericardiocentesis in 14(2 .02%).Primary PCI was done in 62(32.88%). The most frequent indication for PCI was STEMI 106(56.16%). Complications like Post-procedural cardiogenic shock in 4 (2.11%) cases, arrhythmias and minor complications in 7 (3.70%), and death in 4 (2.11%) patients was witnessed. Similarly, periprocedural MI and contrast induced nephropathy (CIN) requiring dialysis stroke or transient ischemic attack were not noted.Cardiac tamponade was observed in 1 (2.02%) patient during PTMC. There was no need of emergency cardiac surgery Percutaneous cardiac intervention was feasible with acceptable complications in a tertiary-level hospital without onsite cardiac surgery backup.