| 1. |
- Björklund, Erik, et al.
(författare)
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Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome.
- 2021
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Ingår i: JAMA network open. - : American Medical Association (AMA). - 2574-3805. ; 4:8
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Tidskriftsartikel (refereegranskat)abstract
- Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P=.34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P=.29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P=.011). Sensitivity analyses confirmed the results.In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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| 2. |
- Björklund, Erik, et al.
(författare)
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Secondary prevention medications after coronary artery bypass grafting and long-term survival : a population-based longitudinal study from the SWEDEHEART registry.
- 2019
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Ingår i: European Heart Journal. - : Oxford University Press. - 0195-668X .- 1522-9645. ; 41:17, s. 1653-1661
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Tidskriftsartikel (refereegranskat)abstract
- AIMS: To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality.METHODS AND RESULTS: All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52-0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73-0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69-0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P < 0.001). There was no association between β-blockers and mortality risk (HR 0.97, 95% CI 0.90-1.06; P = 0.54).CONCLUSION: The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned.
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| 3. |
- Romlin, Birgitta, 1962, et al.
(författare)
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Clinical course and outcome after treatment with ventricular assist devices in paediatric patients: A single-centre experience
- 2021
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Ingår i: Acta Anaesthesiologica Scandinavica. - : Wiley. - 0001-5172 .- 1399-6576. ; 65:6, s. 785-791
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Tidskriftsartikel (refereegranskat)abstract
- Background: Heart failure is a rare condition in the paediatric population, associated with high morbidity and mortality. When medical therapy is no longer sufficient, mechanical circulatory support such as a ventricular assist device can be used to bridge these children to transplant or recovery. Coagulation-related complications such as thrombi, embolism and bleeding events represent the greatest challenge in paediatric patients on mechanical support. We aimed to describe the outcomes and coagulation-related complications in this patient population at our institution. Methods: A total of 20 patients with either Berlin Heart EXCOR® or HeartWare® implantation were reviewed in this retrospective study. Study endpoints were survival to heart transplant, weaning due to recovery or death. Thrombotic events were defined as thrombus formation in the device or in the patient, or cardioembolic strokes. Bleeding events were defined as events requiring interventional surgery or transfusion of red blood cells. Results: The aetiology of heart failure included cardiomyopathy (n=12), end-stage congenital heart disease (n=6) and myocarditis (n=2). Of the 20 patients, 12 were bridged to transplant, 7 recovered and could be weaned and 1 died. The median duration of mechanical support was 84days (range: 20-524days). At least one major or minor bleeding event occurred in 45% of the patients. Thrombotic events occurred 21 times in 10 patients. Four of the patients (20%) had no bleeding or thromboembolic event. Conclusion: In all, 95% of the patients were successfully bridged to transplant or recovery. Bleeding events and thrombotic events were common. © 2021 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
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| 4. |
- Romlin, Birgitta S, et al.
(författare)
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Earlier detection of coagulopathy with thromboelastometry during pediatric cardiac surgery: a prospective observational study.
- 2013
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Ingår i: Paediatric anaesthesia. - : Wiley. - 1460-9592. ; 23:3, s. 222-7
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Tidskriftsartikel (refereegranskat)abstract
- Objective Earlier detection of coagulopathy in pediatric cardiac surgery patients. Aim To determine whether thromboelastometry (TEM) analysis before weaning from cardiopulmonary bypass (CPB) and hemoconcentration is predictive of post-CPB results and whether analysis of clot firmness already after 10 min yields reliable results. Background Cardiac surgery with CPB induces a coagulopathy that may contribute to postoperative complications. Earlier detection increases the possibility of initiating countermeasures. Methods/Material Fifty-six pediatric cardiac surgery patients were included in a prospective observational study. HEPTEM and FIBTEM clotting time (CT), clot formation time (CFT), and clot firmness after 10 min (A10) and at maximum (MCF) were analyzed during CPB and after CPB and ultrafiltration with modified rotational thromboelastometry (ROTEM®). The analyses were compared, and correlations and differences were calculated. Results Hemoconcentration with modified ultrafiltration increased hematocrit from 28 ± 3 to 37 ± 4% (P < 0.001). Correlation coefficients of the TEM variables during and after CPB ranged from 0.61 to 0.82 (all P < 0.001). HEPTEM-CT and HEPTEM-MCF differed significantly but the differences were marginal. Both HEPTEM and FIBTEM A10 measurements during CPB were significantly less than MCF (P < 0.001 for both), but the correlations were highly significant (HEPTEM: r = 0.95, P < 0.001; FIBTEM: r = 0.96, P < 0.001), and the differences were predictable, with narrow confidence intervals (HEPTEM: −8.2 mm (−8.9 to −7.5); FIBTEM: −0.5 mm (−0.7 to −0.3). Conclusion The results suggest that intraoperative TEM analyses can be accelerated by analyzing HEPTEM/FIBTEM on CPB before hemoconcentration and by analyzing clot firmness already after 10 min.
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| 5. |
- Romlin, Birgitta S, et al.
(författare)
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Excellent Outcome With Extracorporeal Membrane Oxygenation After Accidental Profound Hypothermia (13.8°C) and Drowning
- 2015
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Ingår i: Critical Care Medicine. - 0090-3493 .- 1530-0293. ; 43:11
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To report outcome and intensive care strategy in a 7-year-old girl with accidental profound hypothermia and drowning. Data Sources and Extraction: Patient records and interviews with search-and-rescue personnel. Study Selection: Case report. Data Synthesis: The girl was rescued after an estimated submersion time of at least 83 minutes in icy sea water. She presented with cardiac arrest, ice in her upper airways, a first-documented nasopharyngeal temperature of 13.8 degrees C, and a serum potassium of 11.3 mmol/L. The patient was slowly rewarmed with extracorporeal membrane oxygenation and made an exceptional recovery after intensive care and a long rehabilitation time. Conclusion: Excellent outcome is possible in children with body temperature and serum potassium reaching the far limits of previously reported human survival and prolonged submersion time.
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| 6. |
- Romlin, Birgitta S, et al.
(författare)
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Intraoperative thromboelastometry is associated with reduced transfusion prevalence in pediatric cardiac surgery.
- 2011
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Ingår i: Anesthesia and analgesia. - 1526-7598. ; 112:1, s. 30-6
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Tidskriftsartikel (refereegranskat)abstract
- Background: The majority of pediatric cardiac surgery patients receive blood transfusions. We hypothesized that the routine use of intraoperative thromboelastometry to guide transfusion decisions would reduce the overall proportion of patients receiving transfusions in pediatric cardiac surgery. Methods: One hundred pediatric cardiac surgery patients were included in the study. Fifty patients (study group) were prospectively included and compared with 50 procedure- and age-matched control patients (control group). In the study group, thromboelastometry, performed during cardiopulmonary bypass, guided intraoperative transfusions. Intraoperative and postoperative transfusions of packed red blood cells, fresh frozen plasma, platelets, and fibrinogen concentrates, and postoperative blood loss and hemoglobin levels were compared between the 2 groups. Results: The proportion of patients receiving any intraoperative or postoperative transfusion of packed red blood cells, fresh frozen plasma, platelets, or fibrinogen concentrates was significantly lower in the study group than in the control group (32 of 50 [64%] vs 46 of 50 [92%], respectively; P < 0.001). Significantly fewer patients in the study group received transfusions of packed red blood cells (58% vs 78%, P = 0.032) and plasma (14% vs 78%, P < 0.001), whereas more patients in the study group received transfusions of platelets (38% vs 12%, P = 0.002) and fibrinogen concentrates (16% vs 2%, P = 0.015). Neither postoperative blood loss nor postoperative hemoglobin levels differed significantly between the study group and the control group. Conclusions: The results suggest that routine use of intraoperative thromboelastometry in pediatric cardiac surgery to guide transfusions is associated with a reduced proportion of patients receiving transfusions and an altered transfusion pattern.
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| 7. |
- Romlin, Birgitta S, et al.
(författare)
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Moderate superficial hypothermia prolongs bleeding time in humans.
- 2007
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Ingår i: Acta anaesthesiologica Scandinavica. - : Wiley. - 0001-5172 .- 1399-6576. ; 51:2, s. 198-201
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: In vitro and in vivo studies have shown that mild systemic hypothermia influences platelet adhesion and aggregation and coagulation reactions. We wanted to test the hypothesis that mild local hypothermia in healthy volunteers with preserved core temperature increased bleeding time. A secondary aim was to evaluate if local cooling influenced whole blood coagulation measured by thrombelastograph (TEG) in the same setting. METHODS: Bleeding time was measured at the left volar forearm at a baseline skin temperature of 32 degrees C and after cooling to 30 degrees C and 28 degrees C in a water bath. Skin temperature was continuously measured by contact thermistors. Measurements of coagulation by TEG were performed at baseline skin temperature before cooling and after cooling to 28 degrees C skin temperature. Tympanic membrane temperature was continuously measured. RESULTS: Compared with baseline, bleeding time was significantly prolonged at 30 degrees C skin temperature and further prolonged at 28 degrees C skin temperature. No significant differences were measured in any of the TEG parameters. During the procedure, tympanic membrane temperature did not change. CONCLUSION: Lowering the skin temperature from 32 degrees C to 30 degrees C and 28 degrees C with a preserved core temperature more than doubled the bleeding time. Whole blood coagulation measured by TEG was not influenced by the local cooling. In addition to core temperature, local temperature may offer information in understanding the surgical site of bleeding.
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| 8. |
- Romlin, Birgitta S, et al.
(författare)
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Monitoring of acetyl salicylic acid-induced platelet inhibition with impedance aggregometry in children with systemic-to-pulmonary shunts.
- 2013
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Ingår i: Cardiology in the young. - 1467-1107. ; 23:2, s. 225-232
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Shunt thrombosis after implantation of systemic-to-pulmonary shunts in paediatric patients is common. Acetyl salicylic acid is used for anti-thrombotic treatment; however, the effect is rarely monitored, although it is known that the response varies. The aim was to determine the effects of acetyl salicylic acid medication on platelet aggregation in children with systemic-to-pulmonary shunts. METHODS: A total of 14 children - median age 12 days; ranging from 3 to 100 days - were included in a prospective observational longitudinal study. All children were treated with oral acetyl salicylic acid (3-5 milligrams per kilogram once daily) after shunt implantation. Acetyl salicylic acid-dependent platelet aggregation in whole blood was analysed with impedance aggregometry (Multiplate®) after addition of arachidonic acid. Analyses were carried out before the primary operation, before and 5 and 24 hours after the first acetyl salicylic acid dose, and after 3-6 months of treatment. The therapeutic range for acetyl salicylic acid was defined as a test result less than 60 units. RESULTS: Acetyl salicylic acid reduced the arachidonic acid-induced platelet aggregation in all but one patient. Of the patients, 93% were in the therapeutic range 5 hours after acetyl salicylic acid intake, 86% were in the range after 24 hours, and 64% after 3-6 months. CONCLUSIONS: Acetyl salicylic acid reduces platelet aggregation after shunt implantation in paediatric patients, but a considerable percentage of the children are outside the therapeutic range. Monitoring of platelet aggregation has the potential to improve anti-platelet treatment after shunt implantation by identifying children with impaired acetyl salicylic acid response.
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| 9. |
- Romlin, Birgitta S
(författare)
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Monitoring of coagulation and platelet function in paediatric cardiac surgery
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Abstract Background: Paediatric cardiac surgery has developed dramatically during the last decades. Today, a wide range of patients is operated on-from premature neonates to grown up children with congenital heart disease. Excessive bleeding during and after cardiac surgery is still common, and it is one of the most serious complications. In this thesis, we consider different aspects of monitoring of coagulation and platelet function during and after paediatric cardiac surgery. The aims were to determine (1) whether thromboelastometry analyses can be accelerated, (2) whether routine use of intraoperative thromboelastometry reduces perioperative transfusions, (3) whether platelet inhibition can be monitored with impedance aggregometry in children with systemic-to-pulmonary shunts, (4) how platelet count and function varies perioperatively, (5) whether ultrafiltration influences coagulation and platelet function, and (6) whether thromboelastometry detects clinically significant platelet dysfunction. Methods: Paediatric patients undergoing cardiac surgery were included in five pro-spective studies. Coagulation was assessed with standard laboratory tests and throm-boelastometry while platelet function was assessed with impedance aggregometry. Results: Thromboelastometry can be accelerated by performing the analysis before ultrafiltration and weaning of cardiopulmonary bypass, and by analyzing clot firmness after 10 minutes. Routine use of intraoperative thromboelastometry reduces the overall proportion of patients receiving transfusions (64% vs. 92%, p < 0.001). Impedance aggregometry can be used to monitor anti-platelet effects of acetyl salicylic acid after shunt implantation in paediatric patients. A substantial proportion of the patients are outside the therapeutic range 3-6 months after surgery. There are substantial reduc-tions both in platelet count and platelet function during and immediately after surgery. Platelet function, but not platelet count, recovers during the first 24 hours after sur-gery. Ultrafiltration has no or limited effect on platelet count, platelet function, and thromboelastometry analyses. Thromboelastometry has acceptable ability to detect intraoperative but not postoperative ADP-induced platelet dysfunction. Conclusion: Monitoring of coagulation and platelet function gives important information about haemostatic disturbances during and after paediatric cardiac surgery. Routine monitoring of the coagulation markedly reduces transfusion requirements in pae-diatric cardiac surgery. After surgery, more specific platelet tests are necessary to assess platelet function. Key words: paediatric cardiac surgery, haemostasis, platelet, coagulation, thromboe-lastometry, impedance aggregometry, coagulopathy, haemoconcentration ISBN 978-91-628-8753-7 Gothenburg 2013
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| 10. |
- Romlin, Birgitta S, et al.
(författare)
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Perioperative monitoring of platelet function in paediatric cardiac surgery by thromboelastometry, or platelet aggregometry?
- 2016
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Ingår i: British Journal of Anaesthesia. - : Elsevier BV. - 0007-0912 .- 1471-6771. ; 116:6, s. 822-828
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Tidskriftsartikel (refereegranskat)abstract
- Background Impaired platelet function increases the risk of bleeding complications in cardiac surgery. Reliable assessment of platelet function can improve treatment. We investigated whether thromboelastometry detects clinically significant preoperative, perioperative, and postoperative adenosine diphosphate (ADP)-dependent platelet dysfunction in paediatric cardiac surgery patients. Methods Fifty-seven children were included in a single-centre prospective observational study. Clot formation (modified rotational thromboelastometry with heparinase, HEPTEM) and platelet aggregation (multiple electrode aggregometry) were analysed at five time points before, during, and after surgery. The accuracy of thromboelastometric indices of platelet function [maximal clot firmness (MCF) and clot formation time (CFT)] to detect ADP-dependent platelet dysfunction (defined as ADP-induced aggregation ≤30 units) was calculated with receiver operating characteristics analysis, which also identified optimal cut-off levels. Positive and negative predictive values for the identified cut-off levels (CFT≥166 s; MCF≤43 mm) to detect platelet function were determined. Results The MCF and CFT were highly accurate in predicting platelet dysfunction during cardiopulmonary bypass [CPB; area under the aggregation curve 0.89 (95% confidence interval 0.80–0.97) and 0.86 (0.77–0.96), respectively] but not immediately after CPB [0.64 (0.48–0.79) and 0.67 (0.52–0.82), respectively] or on arrival at the intensive care unit [0.53 (0.37–0.69) and 0.60 (0.44–0.77), respectively]. The positive and negative predictive values were acceptable during CPB (87 and 67%, respectively, for MCF≤43 mm; 80 and 100% for CFT≥166 s) but markedly lower after surgery. Conclusion In paediatric cardiac surgery, thromboelastometry has acceptable ability to detect ADP-dependent platelet dysfunction during, but not after, CPB.
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