12 SCIENTIFIC SESSIONS DAILY NEWS | Day 3 Monday, Nov. 18, 2024 Coronary and valvular heart disease late-breaking science Research from four abstracts highlight oxygenation strategies, DOACs and novel agents to optimize cardiac surgery and outcomes post-myocardial infarction. They found that: • Liberal or restrictive oxygenation may be safe for patients undergoing cardiopulmonary bypass-assisted coronary artery bypass grafting or aortic valve replacement. • Perioperative novel exenatide, a GLP-1 agonist therapy, did not benefit cardiac surgery patients. • Edoxaban shows clinical benefit in patients after bioprosthetic valve replacement. • Spironolactone may reduce heart failure but did not reduce primary outcomes in patients after acute myocardial infarction. Liberal or conservative oxygenation strategy during cardiac surgery may be considered Adequate oxygenation is essential for preserving organ function during coronary artery bypass grafting or aortic valve replacement surgery. Traditionally, high levels of oxygenation have been applied during extracorporeal circulation. Still, a conservative or liberal oxygenation strategy could be considered for patients undergoing these surgical interventions, according to the Efficacy of Restrictive versus Liberal Oxygenation in Patients undergoing Coronary Artery Bypass Grafting or Aortic Valve Replacement, results of one of two co-primary interventions independently investigated in the GLORIOUS trial. The 2-by-2, single-center clinical trial randomized 1,400 patients undergoing elective or subacute coronary artery bypass grafting and/ or surgical aortic valve replacement from 2016 to 2021 to a conservative oxygenation strategy of 50% fraction of inspired oxygen (FiO2) versus a liberal oxygenation strategy of 100% FiO2 during cardiopulmonary bypass surgery and for the first hour after weaning. The primary outcome was time to the first occurring composite endpoint during follow-up, including death, renal failure requiring renal replacement therapy, stroke, new onset heart failure or any readmission for heart failure. The trial was designed as event driven, and accordingly, the follow-up period was a priori defined to continue until a total of 323 events had occurred. Secondary endpoints included predefined safety endpoints during the index admission, such as surgical site infection, acute kidney injury, hypoglycemia, pancreatitis, a relative reduction of ejection fraction of 50% compared to baseline, reoperation for bleeding and any cause and post-surgical myocardial infarction. Additionally, re-admission for cardiovascular causes within 12 months was monitored. Wiberg Overall, oxygenation at 50% versus 100% did not affect the composite endpoint of organ injury in adults undergoing cardiopulmonary bypass-assisted cardiac surgery after a median follow-up of 5.9 years. “The neutral results of our trial suggest that it’s safe to only administer 50% oxygen during cardiopulmonary bypass and that if you are worried about endorgan perfusion, it’s also safe to administer 100% oxygen,” said Sebastian Wiberg, MD, PhD, clinical associate professor at Copenhagen University Hospital Rigshospitalet in Denmark. “Our results show that you should feel free to administer the oxygenation strategy best suited for the patient.” GLP-1 analog exenatide did not show benefit during cardiac surgery Infusion with the GLP-1 analog exenatide initiated before cardiopulmonary bypass-assisted coronary artery bypass grafting and/ or surgical aortic valve replacement did not improve outcomes, according to a second independent co-primary endpoint investigated in the GLORIOUS trial. The 2-by-2 single-center, eventdriven trial randomized 1,400 patients undergoing elective or subacute coronary artery bypass grafting and/or surgical aortic valve replacement from 2016 to 2021 to a six-hour and 15-minute infusion of 17.4 micrograms of the GLP-1 analog exenatide or placebo initiated after anesthesia prior to surgery in a double-blind fashion. “Based on a number of preclinical studies from 2010 to 2015 in stroke and myocardial infarction, which showed that treatment with exenatide could reduce final cerebral and myocardial infarction size, we had hypothesized that initiating a novel treatment of exenatide could prevent some of the organ damage that occurs during cardiopulmonary bypass-assisted heart surgery,” Wiberg said. The composite primary endpoint assessed throughout follow-up was death, renal failure requiring renal replacement therapy, stroke, new onset heart failure or any readmission for heart failure until 323 events. Secondary endpoints included predefined safety endpoints during the index admission, such as surgical site infection, acute kidney injury, hypoglycemia, pancreatitis, a relative reduction of ejection fraction of 50% compared to baseline, reoperation for bleeding and any cause, and post-surgery myocardial infarction. Additionally, re-admission for cardiovascular causes within 12 months was monitored. Results showed that perioperative exenatide treatment did not reduce mortality or morbidity from renal failure, stroke or heart failure, compared to placebo, after a median follow-up of 5.9 years. Still, the study adds to the body of evidence for cardiac surgery approaches to consider, or not. “During cardiac surgery, we have many different strategies to choose from, many of which are based on a very low level of evidence,” Wiberg said. “It’s important to evaluate some of them in a clinical setting.”
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