To Örebro University

BACKGROUND: Management of severe aortic stenosis (AS) has evolved over the past decade, driven by the widespread adoption of transcatheter aortic valve implantation (TAVI). This study aims to assess trends in procedural volumes, patient characteristics, and outcomes for patients undergoing TAVI or surgical aortic valve replacement (SAVR) in Sweden.

METHODS: This was a descriptive, non-comparative, nationwide cohort study using the SWEDEHEART registry. We included 21,383 patients who underwent TAVI or SAVR between 2013 and 2023 (11,366 TAVI and 10,017 SAVR). Trends in patient characteristics, preoperative risk, complications and mortality were examined.

FINDINGS: TAVI procedures increased from 307 (26.1%, n = 307/1174) in 2013 to 1851 (71.2%, n = 1851/2601) in 2023, while SAVR volumes declined from ∼1000 annually before 2018 to roughly 750 procedures annually. Median age of TAVI patients were 81 (IQR 77, 85) years and 71 (IQR 65, 76) years for SAVR patients. The median EuroSCORE II for TAVI decreased from 5.6 (IQR 3.3, 10.2) to 2.7 (IQR 1.7, 4.6) (p = 0.002), and STS-PROM from 3.3 (IQR 1.9, 4.1) to 1.6 (IQR 1.1, 2.8) (p = 0.0021). Among SAVR patients, EuroSCORE II decreased from 1.5 (IQR 1.0, 2.3) to 1.3 (IQR 0.9, 2.1) (p = 0.022) and STS-PROM from 1.8 (IQR 1.2, 3.0) to 1.6 (IQR 1.1, 2.6) (p = 0.0082). Any in-hospital complications declined significantly for TAVI (29.2%, n = 210/719 to 13.2%, n = 244/1851), while SAVR complication rates increased slightly (18.4%, n = 354/1921 to 18.7%, n = 140/750). In-hospital mortality for TAVI declined from 3.6% (n = 26/719) to 1.0% (n = 18/1851), and 1-year mortality from 11.1% to 6.9% (p = 0.019). SAVR in-hospital all-cause death decreased from 1.6% to 0.4% (n = 3/750) and 5.0% to 2.2% for 1-year mortality (p = 0.013).

INTERPRETATION: TAVI has become the predominant treatment strategy for AS in Sweden expanding access within the treated cohort. Despite this, current 2023 SAVR results demonstrate similar in-hospital complication rates compared to TAVI (18.7% vs 13.2%), but lower in-hospital (0.4% vs 1.0%) and 1-year mortality rates (2.2% vs 6.9%). 

BACKGROUND: There is limited knowledge regarding how long prepared sterile goods can wait before becoming contaminated. We investigated whether surgical goods could be prepared the day before surgery and kept sterile overnight in the operating room, if protected by sterile covers.

METHODS: Sterile surgical goods for open-heart surgeries (n=70) were randomized to preparation on the morning of the operation or on the previous evening. Exposure time was the total time between preparation and use. Primary outcome was bacterial growth reported as colony forming units (cfu), isolated on 840 agar plates. The protocol was registered with ClinicalTrials.gov (NCT05597072).

RESULTS: When the agar plates were protected with sterile covers, exposure time had no impact (intervention group: 7 cfu, control group: 17 cfu). Without protection, longer exposure time was associated with more cfu (p=0.016). A total of 499 cfu were isolated, displaying 59 different types of bacteria including 13 resistant Staphylococcus epidermidis, 6 (46%) of which were multidrug resistant.

CONCLUSIONS: Sterile goods could wait in the operating room for at least 15 hours before use without increased risk of bacterial air contamination, if protected with sterile covers. However, if the goods were not covered, bacterial air contamination occurred over time.

BACKGROUND AND AIMS: No-touch saphenous vein harvesting may enhance graft patency and improve clinical outcomes after coronary artery bypass grafting (CABG).

METHODS: In this registry-based, randomized trial, patients undergoing CABG were randomly assigned to no-touch or conventional harvesting. The primary composite outcome was the proportion of patients with occluded/stenosed >50% vein graft on coronary computed tomography angiography, or who underwent percutaneous coronary intervention to a vein graft, or died. Secondary outcomes included clinical outcomes and leg wound complications.

RESULTS: A total of 902 patients were enrolled with a mean total number of distal vein anastomoses of 2.0 (SD 0.87). The primary endpoint occurred in 90/454 (19.8%) of patients randomized to no-touch and in 107/446 (24.0%) of patients randomized to the conventional technique [difference, -4.3 percentage points; 95% confidence interval (CI) -10.1-1.6; P = .15] at a mean follow-up time of 3.5 (SD 0.1) years. The composite of death, myocardial infarction, or repeat revascularization at 4.4 (SD 1.3) years occurred in 57/454 (12.6%) and 44/446 (9.9%) in the no-touch and conventional groups, respectively (hazard ratio 1.3; 95% CI, 0.87-1.93). Leg wound complications were more common in patients assigned to no-touch harvesting at 3 months [107/433 (24.7%) vs. 59/427 (13.8%); difference, 10.9 percentage points; 95% CI 5.7-16.1]. At 2 years, 189/381 (49.6%) vs. 91/361 (25.2%) had remaining leg symptoms (difference, 24.4 percentage points; 95% CI 17.7-31.1).

CONCLUSIONS: No-touch vein graft harvesting for CABG was not superior to conventional open harvesting in reducing vein graft failure or clinical events after CABG but increased leg wound complications. The primary outcome requires cautious interpretation due to a lower-than-expected number of primary events.

BACKGROUND: Patients benefit from antiplatelet therapy after coronary-artery bypass grafting (CABG) for an acute coronary syndrome. Whether the addition of ticagrelor to aspirin, as compared with aspirin alone, further reduces the risk of adverse cardiovascular outcomes is unclear.

METHODS: In this open-label, registry-based, clinical trial conducted at 22 Nordic cardiothoracic surgery centers, we randomly assigned patients in a 1:1 ratio to receive either ticagrelor plus aspirin or aspirin alone for 1 year after CABG for an acute coronary syndrome. The primary outcome was a composite of death, myocardial infarction, stroke, or repeat revascularization, evaluated at 1 year. A key secondary outcome was net adverse clinical events, defined as a primary-outcome event or major bleeding.

RESULTS: A total of 2201 patients were randomly assigned to receive ticagrelor plus aspirin (1104 patients) or aspirin alone (1097 patients). The mean age of the patients was 66 years, and 14.4% were women. A primary-outcome event occurred in 53 patients (4.8%) in the ticagrelor-plus-aspirin group and 50 (4.6%) in the aspirin-alone group (hazard ratio, 1.06; 95% confidence interval [CI], 0.72 to 1.56; P = 0.77). Net adverse clinical events occurred in 9.1% of patients in the ticagrelor-plus-aspirin group and 6.4% in the aspirin-alone group (hazard ratio, 1.45; 95% CI, 1.07 to 1.97). Major bleeding occurred in 4.9% of patients in the ticagrelor-plus-aspirin group and 2.0% in the aspirin-alone group (hazard ratio, 2.50; 95% CI, 1.52 to 4.11).

CONCLUSIONS: Among patients who underwent CABG for an acute coronary syndrome, ticagrelor plus aspirin did not result in a lower incidence of death, myocardial infarction, stroke, or repeat coronary revascularization than aspirin alone at 1 year. (TACSI ClinicalTrials.gov number, NCT03560310; EudraCT number, 2017-001499-43; EU Clinical Trials number, 2023-508551-40-00.).

OBJECTIVES: Postoperative atrial fibrillation (POAF) is the most common perioperative arrhythmia. The association of POAF with negative short-term outcomes after cardiac surgery is well understood; however, the association of POAF with long-term morbidity and mortality is not well described. We compared the risk of long-term clinical outcomes (up to 9 years postdischarge) in patients with and without POAF following open-chest cardiac surgery.

METHODS: This observational, retrospective cohort study used data from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) Swedish Cardiac Surgery Registry and National Board of Health and Welfare. Patients aged 55 to 90 years who underwent open-chest coronary artery bypass and/or valvular surgery between 2010 and 2019 were included. Clinical outcomes were adjusted for differences in baseline demographics and clinical history using multivariable Cox regression.

RESULTS: A total of 30,870 patients with a mean age of 69.2 years were included in the study (no POAF, n = 20,734; POAF, n = 10,136). The median follow-up was 4.6 years. After adjustment, POAF was associated with a significantly higher risk of recurrent atrial fibrillation (hazard ratio [HR], 2.30; 95% CI, 2.21-2.41), heart failure (HR, 1.17; 95% CI, 1.10-1.25), chronic kidney disease (HR, 1.15; 95% CI, 1.07-1.24), all-cause mortality (HR, 1.11; 95% CI, 1.04-1.18), and cardiovascular mortality (HR, 1.16; 95% CI, 1.06-1.26). POAF was also associated with a numerically higher risk of ischemic stroke and major bleed, but these findings were not statistically significant after adjustment.

CONCLUSIONS: These data provide further insight into the long-term clinical outcomes associated with POAF in patients undergoing cardiac surgery.

INTRODUCTION: Surgical site infection after saphenous vein harvest is common, with reported leg wound infection rates ranging from 2 to 24%. There have been few investigations into sex-related differences in complication rates. Moreover, varied effects of smoking have been reported. The aim of this study was to investigate risk factors such as gender and smoking, associated with surgical site infection after vein graft harvesting in coronary artery bypass grafting surgery.

METHODS: We included 2,188 consecutive patients who underwent coronary artery bypass grafting surgery with at least one vein graft at our centre from 2009 to 2018. All patients were followed up postoperatively. Risk factors for leg wound infection requiring antibiotic treatment and surgical revision were analysed using logistic regression analysis.

RESULTS: In total, 374 patients (17.1%) received antibiotic treatment and 154 (7.0%) underwent surgical revision for leg wound infection at the harvest site. Female sex, high body mass index, diabetes mellitus, longer operation time, peripheral vascular disease and direct oral anticoagulants were independently associated with any leg wound infection at the harvest site. Among surgically revised patients, female sex and insulin or oral treatment for diabetes mellitus as well as longer operation time were independent risk factors. Smoking was not associated with leg wound infection.

CONCLUSION: Female sex is associated with increased risk of leg wound infection. The underlying mechanism is unknown. In the current population, previous or current smoking was not associated with an increased risk of leg wound infection.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic, which commenced in 2020, is known to frequently cause respiratory failure requiring intensive care, with occasional fatal outcomes. In this study, we aimed to conduct a retrospective nationwide observational study on the influence of the pandemic on cardiac surgery volumes in Sweden.

Results: In 2020, 9.4% (n = 539) fewer patients underwent open-heart operations in Sweden (n = 5169) than during 2019 (n = 5708), followed by a 5.8% (n = 302) increase during 2021 (n = 5471). The reduction was greater than 15% in three of the eight hospitals in Sweden performing open-heart operations. Compared to 2019, in 2020, the waiting times for surgery were longer, and the patients were slightly younger, had better renal function, and a lower European System for Cardiac Operative Risk Evaluation; moreover, few patients had a history of myocardial infarction. However, more patients had insulin-treated diabetes mellitus, hypertension, peripheral vascular disease, reduced left ventricular function, and elevated pulmonary artery pressure. Urgent procedures were more common, but acute surgery was less common in 2020 than in 2019. Early mortality and postoperative complications were low and did not differ during the three years.

Conclusion: The 9.4% decrease in the number of heart surgeries performed in Sweden during the 2020 COVID-19 pandemic, compared to 2019, partially recovered during 2021; however, there was no backlog of patients awaiting heart surgery.

BACKGROUND: Glutamate plays a key role for post-ischaemic recovery of myocardial metabolism. According to post hoc analyses of the two GLUTAMICS trials, patients without diabetes benefit from glutamate with less myocardial dysfunction after coronary artery bypass surgery (CABG). Copeptin reflects activation of the Arginine Vasopressin system and is a reliable marker of heart failure but available studies in cardiac surgery are limited. We investigated whether glutamate infusion is associated with reduced postoperative rises of plasma Copeptin (p-Copeptin) after CABG.

METHODS: A prespecified randomised double-blind substudy of GLUTAMICS II. Patients had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0 and underwent CABG ± valve procedure. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was commenced 10-20 min before the release of the aortic cross-clamp and then continued for another 150 min P-Copeptin was measured preoperatively and postoperatively on day one (POD1) and day three. The primary endpoint was an increase in p-Copeptin from the preoperative level to POD1. Postoperative stroke ≤24 h and mortality ≤30 days were safety outcomes.

RESULTS: We included 181 patients of whom 48% had diabetes. The incidence of postoperative mortality ≤30 days (0% vs. 2.1%; p = .50) and stroke ≤24 h (0% vs. 3.2%; p = .25) did not differ between the glutamate group and controls. P-Copeptin increased postoperatively with the highest values recorded on POD1 without significant inter-group differences. Among patients without diabetes, p-Copeptin did not differ preoperatively but postoperative rise from preoperative level to POD1 was significantly reduced in the glutamate group (73 ± 66 vs. 115 ± 102 pmol/L; p = .02). P-Copeptin was significantly lower in the Glutamate group on POD1 (p = .02) and POD 3 (p = .02).

CONCLUSIONS: Glutamate did not reduce rises of p-Copeptin significantly after moderate to high-risk CABG. However, glutamate was associated with reduced rises of p-Copeptin among patients without diabetes. These results agree with previous observations suggesting that glutamate mitigates myocardial dysfunction after CABG in patients without diabetes. Given the exploratory nature of these findings, they need to be confirmed in future studies.

BACKGROUND: Sternal wound infections (SWI) and aortic graft infections (AGI) are serious complications after cardiac surgery. Staphylococcus aureus and coagulase-negative staphylococci are the most common causes of SWI, while AGI are less studied. AGI may occur from contamination during surgery or postoperative haematogenous spread. Skin commensals, such as Cutibacterium acnes, are present in the surgical wound; however, their ability to cause infection is debated.

AIM: The aim of this study was to investigate the presence of skin bacteria in the sternal wound and to evaluate their possible ability to contaminate surgical materials.

METHODS: We included 50 patients that underwent coronary artery bypass graft surgery and/or valve replacement surgery at our centre from 2020 to 2021. Cultures were collected from skin and subcutaneous tissue at two time points during surgery, and from pieces of vascular graft and felt that were pressed against subcutaneous tissue. The most common bacterial isolates were tested for antibiotic susceptibility with disk diffusion and gradient tests.

FINDINGS: Cultures from skin had bacterial growth in 48% of patients at surgery start and in 78% after two hours, and cultures from subcutaneous tissue were positive in 72% and 76% of patients, respectively. The most common isolates were C. acnes and S. epidermidis. Cultures from surgical materials were positive in 80-88%. No difference in susceptibility was found for S. epidermidis isolates at surgery start compared to after two hours.

CONCLUSIONS: The results suggest that skin bacteria are present in the wound and may contaminate surgical graft material during cardiac surgery.