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Analysing Myocardial Dysfunction after Cardiac Surgery using CMR Strain
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Methodology: Between January 2012 and June 2015, a total of 126 patients 80 years and over who underwent cardiac surgery at Blackrock Clinic, Ireland were analysed. Data included perioperative, intraoperative and postoperative course. Results: The mean age was 82.09 (SD1.86). 88 (70%) male, 38 female (30%), BMI mean 27.43 (SD4.19), Logistic Euro score mean 9.17(SD6.40), Diabetes 17%, Elective 79.36%, Urgent 16.66%, Emergency 3.96%. Procedures: Total % CABG Alone 43 34.13% CABG + Valve 31 24.60% Valve alone 25 19.84% CABG + valve + other 12 9.52% Valve + other 10 7.94% CABG + other 3 2.38% Other 2 1.59% Total CPB minutes mean 95.90 (SD42.00). Postoperative reoperation for bleeding/tamponade n=17(13.49%), insertion of pacemaker n=5(3.97%), tracheotomy n=5(3.97%), sternal rewiring n=1(0.79%) Length of ICU stay days mean 4.83(SD7.45), renal dialysis n=6(4.76%), stroke n=2(1.58%), length of hospital stay days mean 22.02(SD27.97). In-hospital mortality n=6 (4.76%) all had CABG+VALVE (Urgent 3, Elective 3). Conclusion: In summary, our single centre analysis suggests that cardiac surgery in octogenarians and patients aged above can be performed with acceptable morbidity and mortality. Our data also suggests that the postoperative complications rates are far greater in these elderly patients who undergo more complex combined cardiac procedures. http://dx.doi.org/10.1016/j.hlc.2015.12.078 Analysing Myocardial Dysfunction after Cardiac Surgery using CMR Strain John-Paul Tantiongco *, Craig Bradbrook, Angela Walls, Joseph Selvanayagam Flinders Medical Centre, Adelaide, SA, Australia Purpose: Myocardial deformation or strain has been useful in detecting early myocardial dysfunction even when ejection fraction is normal. This is evident in particular using Global Longitudinal Strain (GLS). Cardiac magnetic resonance imaging is the gold standard in cardiac volumetry. Historically, strain in CMR required separate tagging sequences that are labour-intensive to analyse. In this study we compare left ventricular myocardial function as analysed by CMR volumetry and CMR strain analysed using ‘tissue tracking’ in patients having cardiac surgery. Methodology: Patients undergoing CABG or CABG/AVR surgery from May 2014 and July 2015 were scanned using CMR before and after surgery. Cardiac magnetic resonance imaging was acquired using a 1.5T magnet and analysed offline using commercially available software (CVI42 v5.1). Mixed effect statistics was used to analyse any change in left ventricular volumetry and strain. Results: We report 11 patients. After surgery, we found no change in CMR left ventricular ejection fraction, with an average increase of 1.01% 1.8 which was not significant (p=0.57). However, in the same patients, CMR tissue tracking shows a reduction in left ventricular Global Longitudinal Strain of 1.5% 0.5 [95%CI 0.52, 2.46] after cardiac surgery, which was significant (p=0.003). Discussion: Strain can be derived with ease from CMR cine images using ‘tissue tracking’. Subendocardial
Abstracts
longitudinal fibres are the most susceptible especially during the early phase of myocardial dysfunction when ejection fraction remains preserved. The utility of myocardial deformation analysis in early or mild dysfunction using CMR strain shows great potential and requires further investigation. http://dx.doi.org/10.1016/j.hlc.2015.12.079 Should all Patients Receive Dual Anti-platelet Therapy following Coronary Artery Bypass Surgery? Trevor Tnay *, Nisal Perera, Siven Seevanayagam, George Matalanis, Sean Galvin Austin Health, Melbourne, VIC, Australia Objective: The benefit of dual antiplatelet therapy (DAPT) is well established in patients with acute coronary syndrome and in those following percutaneous coronary intervention. The indication for and benefits of DAPT in patients following coronary artery bypass (CABG) grafting is less clear. Methods: To investigate the role of DAPT in patients undergoing CABG a best evidence topic was constructed according to a structured protocol. This is fully described in the Interactive Cardiovascular and Thoracic Surgery Journal. Results: 506 papers were found using the reported search. From these 13 papers were identified that provided the best evidence to answer the question. Conclusions: The role of aspirin therapy post-CABG is well-established. The additional benefit of a second antiplatelet such as clopidogrel is less clear, with the majority of studies demonstrating no difference in outcomes when clopidogrel is used with aspirin postoperatively. The role for newer antiplatelets such as ticagrelor has not been established. Two relatively large RCTs have demonstrated some benefit of the addition of clopidogrel in SVG patency; however, one was limited by a lack of blinding by the investigators. The other RCT looked purely at Off Pump Coronary Artery Bypass Grafting (OPCABG) and other trials have indicated that clopidogrel may assist in overcoming the hypercoaguable state associated with OPCABG. However, the majority of RCTs demonstrated no clear benefit. We suggest that clopidogrel should not routinely be prescribed after CABG and that it should only be considered in patients undergoing OPCABG with multiple SVGs or patients with true aspirin resistance. http://dx.doi.org/10.1016/j.hlc.2015.12.080 Total Aortic Repair for Acute Type A Aortic Dissection Trevor Tnay *, Nisal Perera, Sean Galvin, Siven Seevanayagam, George Matalanis Austin Health, Melbourne, VIC, Australia Objectives: Malperfusion or persistent perfusion of the false lumen (FL) with acute type A aortic dissections is a
Methodology: Between January 2012 and June 2015, a total of 126 patients 80 years and over who underwent cardiac surgery at Blackrock Clinic, Ireland were analysed. Data included perioperative, intraoperative and postoperative course. Results: The mean age was 82.09 (SD1.86). 88 (70%) male, 38 female (30%), BMI mean 27.43 (SD4.19), Logistic Euro score mean 9.17(SD6.40), Diabetes 17%, Elective 79.36%, Urgent 16.66%, Emergency 3.96%. Procedures: Total % CABG Alone 43 34.13% CABG + Valve 31 24.60% Valve alone 25 19.84% CABG + valve + other 12 9.52% Valve + other 10 7.94% CABG + other 3 2.38% Other 2 1.59% Total CPB minutes mean 95.90 (SD42.00). Postoperative reoperation for bleeding/tamponade n=17(13.49%), insertion of pacemaker n=5(3.97%), tracheotomy n=5(3.97%), sternal rewiring n=1(0.79%) Length of ICU stay days mean 4.83(SD7.45), renal dialysis n=6(4.76%), stroke n=2(1.58%), length of hospital stay days mean 22.02(SD27.97). In-hospital mortality n=6 (4.76%) all had CABG+VALVE (Urgent 3, Elective 3). Conclusion: In summary, our single centre analysis suggests that cardiac surgery in octogenarians and patients aged above can be performed with acceptable morbidity and mortality. Our data also suggests that the postoperative complications rates are far greater in these elderly patients who undergo more complex combined cardiac procedures. http://dx.doi.org/10.1016/j.hlc.2015.12.078 Analysing Myocardial Dysfunction after Cardiac Surgery using CMR Strain John-Paul Tantiongco *, Craig Bradbrook, Angela Walls, Joseph Selvanayagam Flinders Medical Centre, Adelaide, SA, Australia Purpose: Myocardial deformation or strain has been useful in detecting early myocardial dysfunction even when ejection fraction is normal. This is evident in particular using Global Longitudinal Strain (GLS). Cardiac magnetic resonance imaging is the gold standard in cardiac volumetry. Historically, strain in CMR required separate tagging sequences that are labour-intensive to analyse. In this study we compare left ventricular myocardial function as analysed by CMR volumetry and CMR strain analysed using ‘tissue tracking’ in patients having cardiac surgery. Methodology: Patients undergoing CABG or CABG/AVR surgery from May 2014 and July 2015 were scanned using CMR before and after surgery. Cardiac magnetic resonance imaging was acquired using a 1.5T magnet and analysed offline using commercially available software (CVI42 v5.1). Mixed effect statistics was used to analyse any change in left ventricular volumetry and strain. Results: We report 11 patients. After surgery, we found no change in CMR left ventricular ejection fraction, with an average increase of 1.01% 1.8 which was not significant (p=0.57). However, in the same patients, CMR tissue tracking shows a reduction in left ventricular Global Longitudinal Strain of 1.5% 0.5 [95%CI 0.52, 2.46] after cardiac surgery, which was significant (p=0.003). Discussion: Strain can be derived with ease from CMR cine images using ‘tissue tracking’. Subendocardial
Abstracts
longitudinal fibres are the most susceptible especially during the early phase of myocardial dysfunction when ejection fraction remains preserved. The utility of myocardial deformation analysis in early or mild dysfunction using CMR strain shows great potential and requires further investigation. http://dx.doi.org/10.1016/j.hlc.2015.12.079 Should all Patients Receive Dual Anti-platelet Therapy following Coronary Artery Bypass Surgery? Trevor Tnay *, Nisal Perera, Siven Seevanayagam, George Matalanis, Sean Galvin Austin Health, Melbourne, VIC, Australia Objective: The benefit of dual antiplatelet therapy (DAPT) is well established in patients with acute coronary syndrome and in those following percutaneous coronary intervention. The indication for and benefits of DAPT in patients following coronary artery bypass (CABG) grafting is less clear. Methods: To investigate the role of DAPT in patients undergoing CABG a best evidence topic was constructed according to a structured protocol. This is fully described in the Interactive Cardiovascular and Thoracic Surgery Journal. Results: 506 papers were found using the reported search. From these 13 papers were identified that provided the best evidence to answer the question. Conclusions: The role of aspirin therapy post-CABG is well-established. The additional benefit of a second antiplatelet such as clopidogrel is less clear, with the majority of studies demonstrating no difference in outcomes when clopidogrel is used with aspirin postoperatively. The role for newer antiplatelets such as ticagrelor has not been established. Two relatively large RCTs have demonstrated some benefit of the addition of clopidogrel in SVG patency; however, one was limited by a lack of blinding by the investigators. The other RCT looked purely at Off Pump Coronary Artery Bypass Grafting (OPCABG) and other trials have indicated that clopidogrel may assist in overcoming the hypercoaguable state associated with OPCABG. However, the majority of RCTs demonstrated no clear benefit. We suggest that clopidogrel should not routinely be prescribed after CABG and that it should only be considered in patients undergoing OPCABG with multiple SVGs or patients with true aspirin resistance. http://dx.doi.org/10.1016/j.hlc.2015.12.080 Total Aortic Repair for Acute Type A Aortic Dissection Trevor Tnay *, Nisal Perera, Sean Galvin, Siven Seevanayagam, George Matalanis Austin Health, Melbourne, VIC, Australia Objectives: Malperfusion or persistent perfusion of the false lumen (FL) with acute type A aortic dissections is a