New-onset postoperative atrial fibrillation (POAF) affects 30-50% of all patients after open heart surgery. This condition is associated with an increased risk of heart failure, future atrial fibrillation, and ischemic stroke, but no causal relationship has yet been established. Patients who develop POAF after cardiac surgery should therefore be closely monitored due to the increased risk of heart failure and recurrence of atrial fibrillation. At the same time, recent studies using implantable monitors show that patients with POAF after coronary artery bypass surgery have a very low atrial fibrillation burden after the first postoperative month. It is still unclear whether anticoagulant therapy reduces the risk of ischemic stroke in these patients. Any decision regarding anticoagulation treatment should therefore be based on an individual assessment of the patient's risk of both stroke and bleeding.

OBJECTIVES:Structural valve deterioration is an inherent limitation of bioprosthetic valves; however, the time it takes to develop varies depending on the valve model. The Sorin Soprano aortic bioprosthetic valve (Sorin Group/LivaNova, Milan, Italy) lacks reported long-term results. This study aims to establish the long-term durability of this bioprosthetic valve in a nationwide cohort. METHODS:All patients who had received the Soprano bioprosthesis during aortic valve replacement in Sweden between 2005 and 2013 were included in the study. Patient characteristics, outcomes, and echocardiographic data were collected using national registries and electronic medical records. Standardized guidelines were used to assess echocardiographic data for the presence of severe structural valve deterioration. RESULTS:A total of 1054 patients (mean age 73.3 years) were included, with 14.0% being ≤65 years at surgery. The Soprano bioprosthesis represented 9.5% of all implanted bioprostheses. During a mean follow-up of 8.6 ± 4.5 years, 206 patients (19.5%) developed severe structural valve deterioration. The cumulative incidence of severe structural valve deterioration at 1, 5, 7, 10, and 15 years was 0.5%, 3.1%, 7.4%, 13.7%, and 22.1%, respectively, in the overall population. The cumulative incidence of structural valve deterioration-related reinterventions at 1, 5, 7, 10, and 15 years was 0%, 0.9%, 3.0%, 7.2%, and 11.5%, respectively. The 30-day mortality rate was 3.8%. CONCLUSIONS:The Soprano bioprosthesis demonstrates high long-term rates of severe structural valve deterioration and deterioration-related reinterventions. These findings suggest the need for increased clinical vigilance and for more frequent echocardiographic monitoring in patients having received this bioprosthetic valve.

OBJECTIVE:The study objective was to compare mortality risks, survival times, and regional differences after coronary artery bypass grafting or percutaneous coronary intervention in patients with diabetes and multivessel disease in a large nationwide cohort of patients. METHODS:The SWEDEHEART registry was used to identify 26,166 patients with diabetes and multivessel disease who underwent percutaneous coronary intervention (n = 16,739, 64.0%) or coronary artery bypass grafting (n = 9427, 36.0%) in Sweden from 2006 to 2020. Individual patient data from 5 mandatory national registries were merged. Inverse probability of treatment weighting was used to compare groups. Sensitivity analyses included multivariable Cox regression and instrumental variable analysis. The median follow-up time was 5.5 years (range, 0-15 years). RESULTS:Weighted all-cause mortality (hazard ratio, 0.80; 95% CI, 0.76-0.84) and cardiovascular mortality (hazard ratio, 0.73; 95% CI, 0.68-0.78) risks were lower after coronary artery bypass grafting compared with percutaneous coronary intervention. The weighted median survival time was 0.9 years longer (95% CI, 0.5-1.4) after coronary artery bypass grafting compared with percutaneous coronary intervention, with markedly longer survival found in patients with left main stem stenosis or 3-vessel disease (+4.1; 95% CI, 3.3-4.9 and +3.4; 95% CI, 2.8-4.0 years, respectively). The results of the sensitivity analyses supported the primary analysis. The percutaneous coronary intervention-to-coronary artery bypass grafting ratio varied markedly across Sweden's 19 health care regions, ranging from 0.9 to 7.6. CONCLUSIONS:Coronary artery bypass grafting was associated with significantly lower risk of all-cause and cardiovascular mortality as well as longer weighted median survival time compared with percutaneous coronary intervention in patients with diabetes and multivessel disease, particularly among patients with left main stem stenosis or 3-vessel disease.

OBJECTIVES:To identify patient- and procedure-related risk factors for surgical site infection following open saphenous vein graft harvesting for coronary artery bypass grafting, using either conventional or no-touch techniques. DESIGN:We conducted a sub-study of the SWEDEGRAFT multicentre randomised trial (ClinicalTrials.gov: ID NCT03501303) comparing conventional and no-touch saphenous vein harvesting for coronary artery bypass grafting. The outcome was leg wound infection, defined as a wound healing disturbance requiring antibiotic treatment. Univariable and multivariable logistic regression assessed associations between prespecified covariates and infection. RESULTS:Of 900 patients, 860 were followed up at 3 months. The proportion of patients with leg wound infections was 12.0%. In the adjusted analysis, covariates independently associated with leg wound infection were the use of the no-touch harvesting technique (adjusted OR 2.78; 95% CI 1.75-4.44) and left ventricular ejection fraction <30% (adjusted OR 3.66; 95% CI 1.29-10.38). Female sex showed a numerically higher risk that did not reach statistical significance (adjusted OR 1.76; 95% CI 0.98-3.16). No significant statistical interaction was found between sex or diabetes mellitus and vein harvest technique regarding the risk of infection. There were significant differences in leg wound infections among the participating centres. CONCLUSIONS:The no-touch vein harvesting technique and poor left ventricular systolic function were independently associated with infectious complications at the vein harvest site after coronary artery bypass grafting. The findings also suggest that female patients may be at higher risk, although the estimate was imprecise. These results could be helpful, should a selective use of the no-touch technique be desired.

BACKGROUND:The optimal management of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear, and evidence supporting routine percutaneous coronary intervention (PCI) beforehand is limited. This study aimed to evaluate whether PCI before TAVR provides clinical benefit compared with conservative management in patients with significant coronary artery disease, using nationwide Swedish registry data. METHODS:This observational study included 2578 Swedish patients with significant coronary artery disease (≥50% angiographic stenosis or physiologically significant lesions) who underwent TAVR between 2008 and 2023. 1182 underwent PCI before TAVR, and 1396 were managed conservatively. The primary outcome was a composite of all-cause mortality, myocardial infarction, and urgent revascularization. Secondary outcomes included the individual components, cardiovascular mortality, any revascularization, stroke, and bleeding. The primary analysis used an instrumental variable approach based on each region's quarterly PCI treatment preference to account for confounding. RESULTS:PCI was not associated with a significant difference in the primary composite outcome (instrumental variable-adjusted hazard ratio, 0.98 [95% CI, 0.85-1.14]; P=0.80) or in all-cause mortality, myocardial infarction, cardiovascular death, stroke, or urgent revascularization. PCI was, however, associated with a lower risk of any revascularization (adjusted hazard ratio, 0.46 [95% CI, 0.30-0.72]; adjusted P=0.002) and a higher risk of bleeding (instrumental variable-adjusted odds ratio, 1.59 [95% CI, 1.23-2.04]; adjusted P=0.002). CONCLUSIONS:In this nationwide cohort, PCI before TAVR did not improve survival or reduce urgent revascularization but did reduce nonurgent revascularization at the cost of increased bleeding. Decisions should be individualized, balancing ischemic and bleeding risks and considering anticipated coronary access after TAVR.

Ischemic heart disease (IHD) involves coordinated molecular changes across heart; yet, their interplay remains poorly understood. Here, we investigated transcriptomic alterations in two heart tissue subtypes, left ventricle (LV) and epicardial adipose tissue (EAT), from age- and BMI-matched healthy and IHD individuals, including diabetic and non-diabetic patients. We performed transcriptomic profiling and systems-level network analysis to identify disease-associated gene expression changes. Our analysis revealed (1) stronger transcriptional responses in EAT than LV, particularly in diabetic individuals, and (2) widespread dysregulation of inflammatory and metabolic pathways, including oxidative phosphorylation, cytokine signaling, and fatty acid degradation, across tissue subtypes. Co-expression network analysis uncovered shared gene modules, with SDHA and OGDH emerging as central, downregulated genes linked to mitochondrial function and inflammation, important processes in IHD pathophysiology. These findings were validated in independent human and mouse datasets. Overall, our integrative analysis identifies conserved molecular signatures across cardiac tissue subtypes, suggesting therapeutic potential in IHD.

BACKGROUND:Acute kidney injury (AKI) is a frequent complication following cardiac surgery involving cardiopulmonary bypass (CPB). This is partly attributable to crystalloid-based priming solutions causing both hemolysis and loss of oncotic pressure with tissue edema. While colloids like albumin and starches have not shown clear benefits, pilot studies using dextran-based priming reported improved oncotic pressure, reduced hemolysis, and lower levels of a renal injury marker, suggesting potential renal protective effects. OBJECTIVE:We hypothesized that a dextran-based priming solution can reduce the incidence of postoperative AKI in high-risk patients undergoing cardiac surgery with CPB. METHODS:In this randomized, controlled, double-blinded, multicenter trial, adult patients with a calculated postoperative AKI risk of ≥ 50% were assigned to receive either a dextran or a crystalloid-based CPB priming solution. The primary outcome was the incidence of AKI within 96 h postoperatively. Secondary outcomes included perioperative hemolysis, net fluid balance, and the need for postoperative renal replacement therapy. RESULTS:The trial was terminated early due to slow enrolment, with 101 of the planned 366 patients recruited. A total of 92 patients were included in the final analysis (43 in the dextran group, 49 in the control group). Postoperative AKI occurred in 81% and 53% of patients in the dextran and control groups, respectively (risk ratio 1.53, 95% confidence interval 1.15-2.06, p = 0.004). The dextran group demonstrated lower intraoperative hemolysis and a more favorable net fluid balance. Postoperative renal replacement therapy was required in 7% of the dextran group and 4% of the control group (p = 0.66). No significant differences in adverse events were observed between the groups. CONCLUSION:In high-risk patients undergoing cardiac surgery with CPB, the use of a dextran-based priming solution was associated with a significantly increased risk of postoperative AKI. EDITORIAL COMMENT:This randomized multicenter trial compared dextran to a crystalloid-based priming solution during cardiopulmonary bypass in participants with elevated risk of acute kidney injury. While the trial had to be terminated due to slow enrolment after about a third of planned cases were included, acute kidney injury was significantly more common in the dextran group, contrary to the primary hypothesis of the study. The study highlights the complexity and logistical challenges of conducting randomized treatment protocols for cardiopulmonary bypass, but at the same time highlights the importance of conducting such studies. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT04293744.

Postoperativt förmaksflimmer (POFF) drabbar 30–50 procent efter öppen hjärtkirurgi. Det är associerat med ökad risk för hjärtsvikt, framtida förmaksflimmer och ischemisk stroke, men något kausalsamband är inte fastställt. Patienterna bör dock följas noggrant på grund av denna risk. Studier med implanterbara monitorer visar att flimmerbördan ofta är mycket låg efter den första postoperativa månaden. Det är fortfarande oklart om antikoagulantia minskar risken för ischemisk stroke, och behandlingen bör därför individualiseras.

OBJECTIVES:Low haematocrit during cardiopulmonary bypass is a known risk factor for acute kidney injury, but it is unclear whether high haematocrit also increases acute kidney injury risk. We examined if a haematocrit range associated with a reduced risk for acute kidney injury could be identified. METHODS:This observational study included cardiac surgery patients operated on between 2016 and 2020, using prospectively collected data from the SWEDEHEART registry and a local cardiopulmonary bypass database. Acute kidney injury was defined by registry-available data as a postoperative serum‑creatinine increase >1.5 times baseline or postoperative initiation of renal replacement therapy. For each predefined haematocrit threshold, weighted exposure was calculated as the accumulated time‑and‑magnitude by which haematocrit rose above or fell below the thresholds. Associations between weighted exposure and acute kidney injury were analysed using multivariable logistic regression adjusted for established acute kidney injury risk factors. RESULTS:A total of 3798 patients were included. Postoperative acute kidney injury occurred in 598 of 3798 patients (15.7%). After adjustment, a non‑linear association between haematocrit weighted exposure during aortic cross‑clamp and acute kidney injury was observed. AKI risk increased with haematocrit below 25% (adjusted odds ratio [aOR] 1.006 per 1 [%×min]; 95% CI 1.002-1.009; P < .001) and above 38% (aOR 1.006 per 1 [%×min]; 95% CI 1.001-1.011; P = .019). CONCLUSIONS:In this cohort, haematocrit exposure below 25% and above 38% during aortic cross-clamp was associated with higher postoperative acute kidney injury risk. Further studies are needed to confirm these findings.

Intracardiac mast cells (CMCs) have previously been shown to contribute to adverse remodeling and heart failure in animal models. As CMCs in human hearts remain unexplored, the aim of this study was to investigate the pathophysiological relevance of human CMCs through transcriptomic profiling. Biopsies were collected from the four heart chambers of heart failure patients undergoing heart transplantation surgery (n = 9), as well as from deceased organ donors without chronic heart failure (n = 5). Using flow cytometry, C-kit+CD45+ CMCs and C-kit-CD45+ hematopoietic cells were identified in all failing and nonfailing hearts and were sorted for RNA sequencing analysis. In comparison with other hematopoietic C-kit-CD45+ cells and CMCs in nonfailing hearts, CMCs in failing hearts demonstrated significant activation of pathways involved in cardiac remodeling and heart failure, including fibrosis-associated and inflammatory pathways. Our results support a role for mast cells in human heart failure and constitute the first in-depth characterization of mast cells in the nonfailing and failing human heart.NEW & NOTEWORTHY Intracardiac mast cells (CMCs) have been shown to contribute to remodeling and fibrosis in animal models. No phenotypical characterization of human CMCs has been conducted before the current transcriptomic profiling study. CMCs isolated from failing human hearts demonstrated activated pathways involved in cardiac remodeling and fibrosis, both compared with other hematopoietic cells and to CMCs in nonfailing hearts. The study suggests that CMCs may constitute a novel candidate for modulation in human heart failure.

Background Surgical closure of the left atrial appendage (LAA) reduces stroke risk in patients with atrial fibrillation (AF) undergoing cardiac surgery. We evaluated the safety and efficacy of prophylactic LAA closure during bioprosthetic surgical aortic valve replacement in patients without prior AF. Methods In this investigator‐initiated, academic, randomized, open‐label, multicenter LAA‐CLOSURE (Left Atrial Appendage CLOSURE for the Prevention of Thromboembolisms in Patients Undergoing Aortic Bioprosthesis Surgery) trial, 921 patients without prior AF undergoing bioprosthetic surgical aortic valve replacement with or without concomitant surgery were randomized and 904 patients included in the modified intention‐to‐treat analysis (prophylactic LAA closure, n=445; or usual care, n=459). Median age was 73 years (interquartile range, 69–76), 34.8% were women, and 49% had concomitant coronary artery disease. The primary end point was a composite of cardiovascular death, stroke, or systemic embolism at 30 days. Results The primary end point occurred in 10 of 434 (2.2%) patients in the LAA closure group and 14 of 452 (3.1%) patients in the control group; however, the treatment effect changed direction at ≈7 days. In the time‐split Cox regression model, hazard ratios were 2.4 (95% CI, 0.62–9.4; P =0.20) between 0 and 7 days and 0.29 (95% CI, 0.080–1.0; P =0.056) between 7 and 30 days. No closure‐related serious complications or differences in bleeding were observed. Postoperative AF occurred in 205 of 445 (46.1%) versus 184 of 459 (40.1%) patients (relative risk, 1.1 [95% CI, 0.99–1.3]; P =0.07), and AF at discharge in 40 of 445 (9.2%) versus 34 of 459 (7.7%) patients (relative risk, 1.2 [95% CI, 0.77–1.8]; P =0.44), in the closure and control groups, respectively. Conclusions Prophylactic LAA closure during bioprosthetic surgical aortic valve replacement was safe and did not increase bleeding. Registration URL: clinicaltrials.gov ; Unique Identifier: NCT02321137.

The effect of no-touch (NT) vs conventional (CON) saphenous vein graft (SVG) harvesting on SVG patency and clinical outcomes in coronary artery bypass remains unclear. Although prior trial-level meta-analyses have generally reported improved patency with NT SVG, outcomes show variability across studies, and evidence from 2 recent, larger multicentre randomized clinical trials is discordant. This individual patient data meta-analysis (IPDMA) will evaluate the impact of harvesting techniques on graft patency and clinical outcomes. A systematic literature search was conducted for randomized clinical trials comparing NT SVG and CON SVG. Studies were eligible if they included at least 1 year of follow-up evaluation with graft imaging. The primary efficacy outcome will be graft failure, defined as graft-level study SVG occlusion. The secondary outcomes will includeleg wound complications, patient-level graft failure, graft malfunction (composite of graft occlusion or stenosis), and major adverse cardiac events (MACE) defined as the composite of all-cause death, myocardial infarction, or any repeat revascularization. A 2-stage IPDMA will be performed. In the first stage, mixed-effects logistic regression models will be fitted separately within each trial. In the second stage, trial-level estimates will be pooled using random-effects models to generate overall effects. Prespecified subgroup analyses will be conducted via a 2-stage framework to evaluate potential effect modification by key patient-level characteristics. This IPDMA will enable more robust evaluation of the effect of harvesting techniques on SVG patency and clinical outcomes, leveraging patient-level datasets for in-depth analyses, particularly among patient subgroups with distinct risk profiles.

INTRODUCTION:New-onset postoperative atrial fibrillation (POAF) is the most common arrhythmia after coronary artery bypass grafting (CABG). Traditionally regarded as a benign and self-limiting event, more recent evidence highlights its association with prolonged hospitalization, increased healthcare utilization, and a heightened risk of stroke, recurrent atrial fibrillation, and heart failure. Understanding its significance is essential for patient care and long-term outcomes. PubMed was searched using terms related to POAF and CABG, supplemented by the review of relevant guidelines and key publications. AREAS COVERED:This narrative review summarizes recent evidence on the epidemiology, pathophysiology, prophylaxis, and treatment of POAF after CABG. Evidence for pharmacological prophylaxis (e.g. amiodarone, beta-blockers) and surgical strategies (e.g. posterior pericardiotomy, atrial pacing) is summarized, along with current approaches for acute management and stroke prevention. The literature reveals significant heterogeneity in treatment strategies, particularly regarding anticoagulation, with emerging trials expected to refine clinical practice. EXPERT OPINION:Current evidence suggests that POAF functions more as an indicator of underlying patient vulnerability than as a direct driver of adverse outcomes. Clinically, management must balance arrhythmia control, stroke and bleeding risk, and individualized anticoagulation decisions. Research efforts should prioritize robust risk stratification tools and randomized evidence to guide tailored therapy.

AIMS:Current guidelines recommend considering long-term oral anticoagulation in patients with new-onset post-operative atrial fibrillation (POAF) after cardiac surgery, balancing stroke and bleeding risk. However, no specific approach to bleeding risk assessment is provided. We explored in a proof-of-concept study whether a bleeding risk score can identify patients with POAF after coronary artery bypass grafting (CABG) with increased risk of post-discharge major bleeding. METHODS AND RESULTS:This observational cohort study included 4436 patients with POAF after CABG in 2009-2020 without oral anticoagulation. The four-item PRECISE-DAPT score (based on age, creatinine clearance, preoperative haemoglobin concentration, and previous bleeding) was calculated for all patients. Bleeding risk was defined as high (≥25 points), medium (16-24 points), or low (≤15 points). Associations between bleeding risk and major bleeding events during the first post-operative year were assessed by Cox regression. Discrimination was evaluated with C-statistics, and calibration was assessed by comparing expected and observed bleeding rates. Major bleeding occurred in 2.1% of patients during the first year. The score classified 36.0% of patients as high bleeding risk. The hazard ratio for high vs. low bleeding risk was 4.81 (95% CI 2.59-8.96). The area under the receiver operating characteristic curve was 0.68 (95% CI 0.63-0.73). Calibration showed good agreement between expected and observed bleeding events in patients with an annual bleeding risk up to 7%. CONCLUSION:A bleeding risk score can be used to stratify patients with POAF after CABG into groups with different post-discharge bleeding risk. Further studies are necessary to identify the optimal risk score and its role in oral anticoagulation decision pathway to improve clinical outcomes.

OBJECTIVES:Elevated red cell distribution width (RDW) has been associated with adverse outcomes in coronary artery disease but its role in bleeding after cardiac surgery is unclear. We evaluated whether preoperative RDW predicts bleeding after isolated coronary artery bypass grafting (CABG). METHODS:This was a nationwide retrospective study of patients undergoing isolated CABG in Iceland, 2003-2019. RDW was analysed continuously (per 1% increase) and dichotomized (>14.0% vs ≤14.0%). Primary bleeding outcomes included transfusion >4 red blood cell units, re-exploration for bleeding, and chest tube output >1000 mL/24h. Multivariable logistic regression adjusted for demographics, comorbidities, operative urgency, cardiopulmonary bypass, and perioperative factors. RESULTS:The study included 1929 patients. Elevated RDW was associated with older age, anaemia, comorbidities, and urgent procedures. After adjustment, higher RDW predicted transfusion >4 RBC units (OR 1.25 per 1%, OR 1.72 for >14.0%), re-exploration (OR 1.30 per 1%, OR 2.39 for >14.0%), and chest tube output >1000 mL/24 h (OR 1.13 per 1%, OR 1.34 for >14.0%). RDW was also associated with greater platelet/plasma use, longer ICU stay, and major complications, but not to 30-day mortality (OR 1.21, 95% CI 0.55-2.52). CONCLUSIONS:Elevated RDW was independently associated with multiple bleeding complications after CABG. RDW may serve as a simple, inexpensive biomarker to improve preoperative bleeding risk stratification in CABG patients.

Background:There is a paucity of contemporary population-based studies on temporal trends in incidence and early complications after open thoracic aortic surgery. This study aimed to assess temporal trends in incidence and early complications of open aortic surgery for ascending aortic aneurysm or dissection in Sweden. Methods:All open thoracic aortic operations for aortic aneurysm or dissection involving the ascending aorta, in Sweden from 2001 to 2020 were included in a nationwide, population-based, observational cohort study. Individual patient data were collected from the SWEDEHEART registry, the National Patient Registry, and the National Cause of Death Register. The incidences of surgery, early postoperative mortality, and stroke rates over time were compared using generalized additive models, separately for patients operated for aneurysms and dissections. Findings:A total of 10,089 procedures in 9829 patients were included. In total, 6429/10,089 operations were performed for aneurysms (63.7%) and 3660/10,089 for dissections (36.3%). The annual incidence of open thoracic aortic operations increased from 26.7 per million inhabitants in 2001 to 64.0 in 2020 (p for trend <0.001). Crude 30-day mortality after first-time surgery was 2.4% (95% confidence interval (CI) 2.0-2.9) for aneurysms and 14.6% (95% CI 13.4-15.8) for dissections. The age- and sex-adjusted 30-day mortality risk for first-time surgery for aneurysm decreased over time (adjusted odds ratio (aOR) 0.33, 95% CI 0.14-0.77) while stroke risk showed a tendency toward decrease (aOR 0.42, 95% CI 0.17-1.06). For first-time surgery for dissections, adjusted 30-day mortality risk decreased significantly (aOR 0.40, 95% CI 0.25-0.64), whereas stroke risk did not change (aOR 1.05, 95% CI 0.64-1.72). Interpretation:The incidence of open thoracic aortic surgery in Sweden for aneurysm and dissection involving the ascending aorta, more than doubled over two decades. Survival after aneurysm and dissection surgery improved during the study period. Funding:This study was supported by the Örebro University Hospital Research Foundation and Nyckelfonden Research Foundation.