Introduction: Aspirin and clopidogrel are the most commonly used antiplatelet agents, either alone or as dual therapy, in patients undergoing CABG surgery to reduce organ ischaemia and mortality. The systematic review aims to explore the resistance to the antiplatelet agents, how to assess it, and the effect of resistance on the outcomes in CABG surgery. Materials & methods: A systematic search is carried out on MEDLINE via Ovid, PubMed, Embase, the Cochrane Library Database and Google Scholar until November 2021 to look for studies evaluating the antiplatelet resistance in patients undergoing both on-pump and off-pump CABG surgery. Only high-quality studies were included after the risk of bias assessment. Results: A total of 17 studies, of which 3 randomised controlled trials and 14 observational studies were included after inclusion criteria is applied. The incidence of aspirin resistance ranges from 11-51.5%, whereas, clopidogrel resistance is 22%. A wide variety of different assessment methods for antiplatelets are reported. Antiplatelet resistance is a predictor of vein graft occlusion, with up to 13 fold increase in occlusion rate. There is no overall effect of aspirin resistance on mortality, stroke or myocardial infarction, however, clopidogrel resistance leads to higher mortality, MI and target vessel revascularisations. The effect of cardiopulmonary bypass on antiplatelet resistance is not clear. Conclusion: There is no uniform definition of antiplatelet resistance. Assessment methods differ greatly and their results are not interchangeable. Antiplatelet resistance is associated with a higher rate of graft occlusion in CABG patients. Aspirin resistance does not influence overall adverse outcomes, however, clopidogrel resistance leads to worse outcomes.

Background: Chest X-rays are routinely obtained after removal of chest drains in patients undergoing cardiac and thoracic surgical procedures. However, a lack of guidelines and evidence could question the practice. Routine chest X-rays increase exposure to ionising radiation, increase healthcare costs and lead to overutilisation of available resources. This review aims to explore the evidence in the literature regarding the routine use of chest X-rays following the removal of chest drains. Materials & Method: A systematic literature search was conducted in PubMed, Medline via Ovid, Cochrane central register of control trials (CENTRAL) and ClinicalTrials.gov without any limit on the publication year. The references of the included studies are manually screened to identify potentially eligible studies. Results: A total of 375 studies were retrieved through the search and 18 studies were included in the review. Incidence of pneumothorax remains less than 10% across adult cardiac, and paediatric cardiac and thoracic surgical populations. The incidence may be as high as 50% in adult thoracic surgical patients. However, the re-intervention rate remains less than 2% across the populations. Development of respiratory and cardiovascular symptoms can adequately guide for a chest X-ray following the drain removal. As an alternative, bedside ultrasound can be used to detect pneumothorax in the thorax after the removal of a chest drain without the need for ionising radiation. Conclusion: A routine chest X-ray following chest drain removal in adult and paediatric patients undergoing cardiac and thoracic surgery is not necessary. It can be omitted without compromising patient safety. Obtaining a chest X-ray should be clinically guided. Alternatively, bedside ultrasound can be used for the same purpose without the need for radiation exposure.

A 41-year-old lady was referred to tertiary cardiothoracic surgery centre following embolisation of patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.