Background: Neurological complications after coronary artery bypass grafting (CABG) reduce quality of life, increase mortality, and inflate resource utilization. The risk of postoperative neurological complications parallels the increasing risk burden of the contemporary patient population. We evaluated the efficacy of remote ischemic preconditioning (RIPC) on inducing neuroprotection.Methods: Seventy patients undergoing first-time CABG were randomly assigned to RIPC or a sham procedure. Structural brain magnetic resonance imaging (MRI) was complemented with functional connectivity MRI to gain a whole-brain global connectivity analysis. Paired neurocognitive and MRI data were acquired pre-and postoperatively. The primary end point was a composite of new ischemic brain lesions and neurocognitive impairment. Secondary end points included brain connectivity profiles, pooled ischemic volumes, and individual components of the primary outcome. The Shapiro-Wilk test was used to determine whether a data set followed a normal distribution. The Fisher exact test was used to calculate the measures of association for categorical variables, whereas continuous data were tested with either the Mann-Whitney U test or the Student t test.Results: There was no between-group difference in the incidence of the primary end point (9 [27%] in the RIPC group vs 8 [24%] in the control group, odds ratio, 1.17 [95% confidence interval, 0.34-4.06]; P ¼ 1.0). Although RIPC did not reduce the incidence of brain ischemia (8/33 [24%] vs 7/33 [21%]; P ¼ 1.0), the pooled ischemic volume was lower in the RIPC group (157 [interquartile range, 125-231] vs 777 [interquartile range, 564-965] mm 3 ; P ¼ .004). Postoperative neurocognition was marginally superior in the RIPC group as evidenced by a lower absolute number of abnormal neurocognitive tests in the RIPC group (7/99 [7%] vs 16/99 [16%]; odds ratio, 0.40 [95% confidence interval, 0.14-1.09]; P ¼ .074). Robust reductions of functional connectivity profiles for the associative thalamus were documented in both groups, irrespective of RIPC (RIPC group, t ¼ 3.31; P <.01; and the control group, t ¼ 3.52; P <.01).Conclusions: Silent brain ischemia occurs frequently after CABG. RIPC did not reduce the incidence of the primary outcome. However, RIPC significantly RIPCAGE study summary. Brain-wide postoperative reductions in associative thalamic functional connectivity (shown in green). Central MessageAlthough RIPC did not reduce the incidence of new brain ischemia, it reduced its pooled volume. Surgery adversely affected global brain connectivity, with RIPC conferring no demonstrable protection. PerspectiveIschemic preconditioning mobilizes the endogenous potential for protection against ischemia incurred by alternating periods of sublethal ischemia and reperfusion. Neuronal injury occurs in response to cardiac surgical interventions at the structural and functional levels. RIPC might have the potential to alleviate brain ischemic cellular damage and might thus provide an additional layer of neuroprotect...

Coronary artery bypass grafting is pivotal in the contemporary management of complex coronary artery disease. Interpatient variability to antiplatelet agents, however, harbors the potential to compromise the revascularization benefit by increasing the incidence of adverse events. This study was designed to define the impact of dual antiplatelet therapy (dAPT) on clinical outcomes among aspirin-resistant patients who underwent coronary artery surgery. We randomly assigned 219 aspirin-resistant patients according to multiple electrode aggregometry to receive clopidogrel (75 mg) plus aspirin (300 mg) or aspirin-monotherapy (300 mg). The primary end point was a composite outcome of all-cause death, nonfatal myocardial infarction, stroke, or cardiovascular hospitalization assessed at 6 months postoperatively. The primary end point occurred in 6% of patients assigned to dAPT and 10% of patients randomized to aspirin-monotherapy (relative risk 0.61, 95% confidence interval 0.25 to 1.51, p = 0.33). No significant treatment effect was noted in the occurrence of the safety end point. The total incidence of bleeding events was 25% and 19% in the dAPT and aspirin-monotherapy groups, respectively (relative risk 1.34, 95% confidence interval 0.80 to 2.23, p = 0.33). In the subgroup analysis, dAPT led to lower rates of adverse events in patients with a body mass index >30 kg/m(2) (0% vs 18%, p <0.01) and those <65 years (0% vs 10%, p = 0.02). In conclusion, the addition of clopidogrel in patients found to be aspirin resistant after coronary artery bypass grafting did not reduce the incidence of adverse events, nor did it increase the number of recorded bleeding events. dAPT did, however, lower the incidence of the primary end point in obese patients and those <65 years.

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Preoperative and postoperative NT-pro-BNP as well as TnT values were significantly higher in patients who subsequently developed AF. TCLG and CRP were not useful in identifying patients at higher risk for AF. Multivariate analysis identified age, preoperative NT-pro-BNP and duration of CPB as independent correlates of AF.

Atria exhibiting greater fibrotic and apoptotic burdens had impaired conduit, reservoir and contractile function, as evaluated by deformation imaging. Among patients with chronic LA volume overload, exposure to long-standing persistent AF induced more pronounced degrees of adverse atrial cellular remodelling. Strain-rate descriptors of atrial reservoir function harboured potential to predict atrial fibrosis and apoptosis.

The advantage in terms of wound infection, wound healing, and scarring has resulted in the recent adoption of endoscopic vein harvesting (EVH) as a standard of care for coronary artery bypass grafting in some centers. However, concerns regarding the quality of these grafts have been raised after recent evidence of decreased graft patency, increased reoperation rate, and myocardial infarct, problems that are associated with vascular trauma caused when using this technique. Simultaneously, an atraumatic, "no-touch" technique for harvesting the saphenous vein was developed producing grafts with improved patency comparable to the internal thoracic artery. However, wound complications remain a problem using this technique. This review outlines the need to consider the poor graft quality that may result from EVH and raises the question what is likely to be the "best practice principle" in saphenous vein harvesting?

Continuous-flow left ventricular assist devices (cf-LVAD) play an important role in the management of patients with advanced heart failure. De novo aortic regurgitation after cf-LVAD implantation may adversely impact device performance. We performed a systematic search of PubMed, SCOPUS, and Cochrane Library for articles reporting on the incidence and predictors of de novo aortic regurgitation among cf-LVAD recipients. Eight studies totaling 548 patients were identified in the meta-analysis. The pooled incidence of de novo AR across the analyzed studies was 37%. Factors influencing its development and progression are older age, persistent aortic valve closure, being female, and duration of cf-LVAD support.

BackgroundCoronary artery disease remains the dominant cause of mortality in developed countries. While platelets have been recognized to play a pivotal role in atherothrombosis, the ideal antiplatelet regime after coronary artery surgery remains elusive.The evolution of CABG has presently moved beyond technical improvements to involve modulation of pharmacologic management designed to improve patient outcomes. The aim of this trial will be to test the hypothesis that the addition of clopidogrel to patients with documented postoperative aspirin resistance will reduce the incidence of major cardiovascular events.MethodsPatients scheduled for isolated coronary artery surgery will be eligible for the study. Patients in whom postoperative multiple electrode aggregometry documents aspirin resistance will be randomized into two groups. The control group will receive 300 mg of aspirin. The dual antiplatelet group will receive 75 mg of clopidogrel in addition to 300 mg of aspirin. Patients will be followed for 6 months. Major adverse cardiac and cerebrovascular events (death from any cause, myocardial infarction, stroke, hospitalization due to cardiovascular pathology) as well as bleeding events will be recorded.DiscussionThis will be the first trial that will specifically address the issue of dual antiplatelet therapy in patients undergoing coronary artery surgery who have been found to be aspirin resistant. In the event that the addition of clopidogrel proves to be beneficial in this subset of surgical patients, this study could significantly impact their future antiplatelet management.This randomized controlled trial has been registered at the ClinicalTrials.gov website (Identifier NCT01159639).