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Background: Aerobic exercise and CPAP benefit patients in the postoperative period of cardiac surgery. To our knowledge, the association of aerobic exercise on an exercise bicycle with CPAP has not yet been demonstrated. Therefore, we aimed to evaluate the effectiveness of physical exercise on a cycle ergometer combined with CPAP in the postoperative period after coronary artery bypass graft surgery., Methods: This was a randomized clinical trial, with recruitment from May 2017 to December 2017 (registered in the Brazilian Clinical Trials Registry: RBR-69CDYF). The step group ( n = 16 subjects) started rehabilitation in the immediate postoperative period with breathing exercises and passive mobilization in the sitting position, progressing to active exercises, ambulation, and stair training. For the intervention group ( n = 15 subjects), dynamic exercises on a cycle ergometer combined with CPAP were added to the step program from the second to the fourth postoperative day in a single daily session., Results: Functional capacity decreased in both groups, but this reduction was not significant in the intervention group ( P = .11). The length of stay in ICU was lower in the intervention group ( P = .050). In both groups there was a decrease in maximum inspiratory and expiratory pressure, as well as in the 1-min sit-to-stand test on the fourth postoperative day compared to the preoperative period., Conclusions: Physical exercise combined with CPAP promoted the maintenance of functional capacity and reduced the length of stay in the ICU., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2020 by Daedalus Enterprises.)

Introduction: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario., Objective: Identify predictors of clopidogrel following CABG., Methods: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG., Results: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032)., Conclusion: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG., Competing Interests: None of the other authors have any conflict of interest to report related to this study.

An adequate assessment of physical function (PF) in Cardiac Rehabilitation (CR) plays a central role in early detection of physical limitations. Traditionally exercise tolerance has been used as an indicator of overall PF. However exercise tolerance has been shown to poorly predict patients' ability to perform daily-life activities. The goal of the present study is to evaluate a new test, named VITTORIO TEST, for assessing various component of daily activities among patients in CR after cardiac surgery. VITTORIO test consists in 8 items that assess lower and upper extremity strength and flexibility, agility, dynamic balance, aerobic capacity. 500 patients (359 males; 141 females) admitted to CR programs following cardiac surgery (349 coronary artery bypass surgery; 151 valvular surgery) were enrolled in the study. They were evaluated with an initial test (T1) (10.7 +/- 6.3 days after cardiac surgery) and a final test (T2) after an in-hospital intensive training program (mean length 16.8 +/- 6.6 days) consisting in stretching, large muscle group and aerobic activity, resistance exercises. Statistical analysis showed a significant improvement of all items at the end of the rehabilitation program. Old patients (>70 years) and particularly females demonstrate exercise improvement comparable to that of younger subjects especially regards lower extremity strength and aerobic capacity. VITTORIO test is inexpensive, simple and easy to perform by the patient. Through the identification and the measurement of different aspects of physical disability, it allows a personalized rehabilitation exercise program. It could be used as an outcome measure of CR programs.

Cardiac Data Bank records of 1,238 patients with triple-vessel disease (greater than or equal to 50% diameter reduction) who had undergone coronary bypass surgery were reviewed and divided into 2 groups depending on whether complete (n = 773) or incomplete (n = 465) revascularization had been accomplished. Patients with complete revascularization had a higher incidence of a normal preoperative electrocardiogram than did patients with incomplete revascularization (23 versus 14%, respectively, p less than 0.0001). The ejection fraction for both completely and incompletely revascularized patients was good (m = 0.60 and 0.57, respectively). The mean number of grafts per patient for the 2 groups was 3.8 and 2.6 (p less than 0.0001). There was no significant difference between the 2 groups with regard to postoperative inotropic requirements (8 and 7%), ventricular arrhythmias (1.8 and less than 1%), necessity for intraaortic balloon pumping (1.6 and 1.5%, hospital mortality (1.2 and 2.8%), or myocardial infarction (4.3 and 4.8%). Survival at 5 years was significantly greater (p less than 0.001) in patients with complete (88.5%) than in those with incomplete revascularization (83.5%). Reemployment occurred more often in patients with complete (52%) than in those with incomplete revascularization (40%) (p less than 0.001), and more patients were free of angina after complete (70%) than after incomplete revascularization (58%) (p less than 0.0005). Long-term survival appeared to be mediated primarily through improved revascularization rather than through differences in left ventricular function.

Between 1975 and 1979 15 patients under 35 underwent aorto-coronary bypass-grafting. The youngest was 24 years old. Out of 1188 revascularized patients over the same period, only 1.26% of surgically treated patients with coronary artery disease were under 35, whereas 4.79% were under 40. The main risk factors were smoking, overweight and hyperlipidemia, and every patient had several risk factors. 12 of 15 patients had preoperative infarctions. 3 patients had single vessel disease, 3 had double vessel disease and 9 had triple vessel disease, the latter two groups with massive and diffuse disease down to the peripheral vessels. By the usual criteria some of them had been refused for revascularization and only their youth and disabling angina without hope of improvement through medical therapy prompted us to operate on them. At operation 2.73 grafts per patient were performed, three of which were internal mammary artery anastomosis. Operative mortality was nil. Only one patient had a perioperative myocardial infarction, without complications or hemodynamic impairment. Another patient sustained a re-infarction four months postoperatively. However, this patient did not reduce any of his risk factors. At postoperative angiography 32 out of 40 grafts performed, i.e. 2.13 grafts per patient, were patent. In 9 patients all grafts were patent, in 4 over 51% of the grafts performed were patent, in 1 two out of four were patent and one single-bypass was subtotally occluded. The angina-free working tolerance increased postoperatively by 70 Watts, i.e, by 100%. These preliminary results with 15 patients under age 35 show that satisfactory medical and professional rehabilitation can be achieved with coronary artery surgery. All but one returned to work as they would otherwise have been unable to do because of disabling angina under maximal medical therapy.