**9. Anticoagulants and antithrombotics management**

Thromboembolism and bleeding associated with anticoagulation comprise about 75% of the complications associated with prosthetic valves. antithrombotic therapy can reduce but not eliminate the possibility of this catrastofe. It is reported that the incidence of perioperative arterial thromboembolism is approximately 0.4 to 1.5% and the annual risk of stroke in high risk patients without anticoagulation is> 5.6% and <2.0% of major bleeding.

The risk for thrombus formation with prosthetic heart valves is seven times higher in the first month after valve replacement during the following months, years intracardiac position independent. The underlying pathophysiology of activation are factors in the systems of intrinsic and extrinsic coagulation of synthetic surface extracorporeal circulation of blood or from contact with surfaces or tissue devoid of collagen, a significant number of surgeons in favor of delaying the anticoagulant because the risk of bleeding, the incidence of pericardial tamponade and reoperation is eight times higher in patients treated with high doses of heparin than in those treated with low-dose heparin for prevention of venous thrombosis.

Anticoagulation is recommended in the following cases:


There is no consensus at the time of initiation of anticoagulation after surgery, but should begin during the first days postoperatively. (5 + -2)

### **10. References**

34 Special Topics in Cardiac Surgery

with a significant decrease in cardiac mortality, unstable angina and arrhythmias 60 days

Its use has been assessed by many studies, but in a perioperative cardiac surgery, Sjölander et.al, conducted a controlled double-blind study of 967 patients with MVR. Patients were randomized 4 to 21 days after RVM receiving 50 mg of metoprolol 2 times per day x 2 weeks and 100 mg of metoprolol per day vs placebo 2 x 2 years. There was no significant difference between the 2 study arms with respect to exercise capacity, however cn patients placebo had a higher rate of chest pain compared with the metoprolol group. On the other hand no significant difference in both groups with regard to revascularization, unstable angina,

Finally, Ferguson et al, in a cohort study investigated the use of preoperative B-blocker in 629 877 patients undergoing CSRC and showed a reduction to 30 days of drug-related mortality (OR 0.90, 95% CI0.87-0.93 ). This decrease was consistent with all groups of

Only one study has examined the effect of calcium antagonists initiated after surgery RVM, Gaudino et al; evaluating the benefits of calcium antagonists after the first year of revascularization. A total of 120 patients with normal perfusion function were randomized after 1 year of tx with 120 mg diatiazem to continue with or stop. No significant differences after 4 years of follow-up among the group of calcium antagonists and those who discontinued tx with respect to recurrence of angina (10% vs 12%), residual ischemia, 17% vs 18%) and cardiac death 2% vs 0%). In short there is little evidence to support the routine use

Despite the known benefits of ACE inhibitors, only 4 studies examined perioperative prophylactic use of ACE inhibitors in patients with MVR. QUO VADIS In the study 149 patients were randomized to quinapril 40mg/día or placebo for 4 weeks before elective surgery RVM, treatment was continued for 1 year. The researchers found that quinapril significantly reduced 1-year clinical events, such as death from cardiovascular causes.

Thromboembolism and bleeding associated with anticoagulation comprise about 75% of the complications associated with prosthetic valves. antithrombotic therapy can reduce but not eliminate the possibility of this catrastofe. It is reported that the incidence of perioperative arterial thromboembolism is approximately 0.4 to 1.5% and the annual risk of stroke in high

The risk for thrombus formation with prosthetic heart valves is seven times higher in the first month after valve replacement during the following months, years intracardiac position independent. The underlying pathophysiology of activation are factors in the systems of intrinsic and extrinsic coagulation of synthetic surface extracorporeal circulation of blood or from contact with surfaces or tissue devoid of collagen, a significant number of surgeons in favor of delaying the anticoagulant because the risk of bleeding, the incidence of pericardial tamponade and reoperation is eight times higher in

patients except those with LVEF <30% where there was no demonstrated benefit.

to 1 year. **Beta blocker** 

**Calcium antagonist** 

**ACEI** 

nonfatal MI or death at 2 years of follow-up.

of calcium antagonists or nitrates after cardiac surgery.

**9. Anticoagulants and antithrombotics management** 

risk patients without anticoagulation is> 5.6% and <2.0% of major bleeding.


Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 37

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**2** 

*Canada* 

**Intra-Aortic Balloon** 

*Southlake Regional Health Centre* 

**Counterpulsation Therapy and Its Role in Optimizing Outcomes in Cardiac Surgery** 

Bharat Datt, Carolyn Teng, Lisa Hutchison and Manu Prabhakar

Several discoveries and inventions in medicine have revolutionized it's practice. Examples would include the discovery of Insulin by Dr William Banting in 1920. The discovery of Heparin by Dr Jay McLean and its first clinical use in Toronto in 1933-36, the advent of the membrane oxygenator, heart lung machines with progressively smaller footprints, intra aortic balloon (IAB) pumps and VAD's (ventricular assist device) would be some of the

The fundamentals of IAB technology were first tested by Harken in 1958, who is credited with the first use of diastolic augmentation. The pump for Harken's system was a failure due to massive hemolysis. Moulopoulous (in the 1960's) from the Cleveland Clinic developed the first successful prototype of an Intra-aortic balloon pump (IABP) which could

The IABP device as we know it was reported by Dr Adrian Kantrowitz (Fig 1) and his team from Grace Sinai hospital in Detroit. The first clinical implant was performed at Maimonides Medical Centre, Brooklyn, NY in Oct 1967 for a 48 yr old woman in cardiogenic shock unresponsive to traditional therapy. The IAB was inserted through a cut down of the left femoral artery (LFA) and pumping performed for 6 hrs. The shock was reversed and the patient discharged. The device was further developed for cardiac surgery by Dr David

Studying the history of counterpulsation elucidates the great strides in IAB technology and its clinical applications. The size of the balloons initially inserted were as large as 15 Fr. Two operations were required for balloon usage, one to insert the balloon by cut down in a femoral artery, and a second operation to remove the balloon. Advances in technology afforded progressively smaller IAB catheter sizes and eventually 8 and 9Fr. balloons were

In 1968 –Kantrowitz and his group began to use the IABP regularly in clinical practice.

The wrapped IAB was developed in 1985. Advances in technology facilitated graduating from cut down insertions to percutaneous and sheathless insertions going from cut down insertions to percutaneous and finally sheathless insertions. Smaller diameter catheters permitted this along with user friendly consoles with automated and real time timing

Since 1979 balloon placement utilizes the Seldinger (percutaneous) technique.

devices which significantly impacted outcomes in cardiac surgery.

Bregman at New York Presbyterian Hospital in 1976.

developed. Current IAB catheter sizes are 7 and 7.5Fr.

**1. Introduction** 

be timed to the cardiac cycle.

algorithms.

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