Prognostic impact of prior percutaneous coronary intervention on patients undergoing coronary artery bypass grafting - A meta-analysis of reconstructed time-to-event data.

The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 ± 1.08 vs 2.08 ± 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 ± 0.82 vs 1.07 ± 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.

Aim: We evaluated the impact of prior percutaneous coronary intervention (PCI) on early and mid-term results in patients undergoing coronary artery bypass grafting (CABG). Methods: Between 2015 and 2020, 938 consecutive patients (mean age 67.4 ± 9.11 years) underwent CABG with prior PCI (n = 121) or primary CABG (n = 817). The mean follow-up was 37 ± 25 (median 36) months. Kaplan-Meier estimates were used to assess survival rates, while Logistic and Cox model analysis regressions assessed the risk of prior PCI and other variables. Results: Six-year survival including in-hospital mortality was 79% ± 6% in CABG with prior-PCI patients vs.88% ± 2% in primary CABG (P = 0.002). As compared with primary CABG, in prior-PCI patients, clinical presentation (acute coronary syndrome, reduced left ventricular ejection fraction, and previous myocardial infarction, P ≤ 0.01, for all comparisons) was worse, comorbidity increased (Euroscore-2, severe chronic renal dysfunction, P &lt; 0.01), and in-hospital mortality was higher (6.6% or 8 patients vs. 1.6% or 13 patients, P &lt; 0.001). Prior PCI was found to be an independent predictor of mortality (HR = 4.23; P = 0.01). Six-year freedom from late all-cause death and cardiac death were 84% ± 6% vs. 90% ± 2% (P = 0.2) and 96% ± 2% vs. 96% ± 1% (P = 0.5), respectively. Independent predictors of all-cause death were advanced age at the operation (P &lt; 0.0001), reduced left ventricular ejection fraction (P = 0.01), severe chronic renal dysfunction (P = 0.02), prior PCI (P = 0.03), and Euroscore-2 (P = 0.05). Prior PCI did not negatively affect late cardiac death (P = 0.5). Conclusion: Patients undergoing CABG after prior PCI have worse perioperative outcomes. Mid-term reduced survival in the prior-PCI patients is mainly due to the concomitant presence of worse clinical presentation and increased comorbidity. Freedom from cardiac death is comparable and satisfactory in both cohorts, highlighting the positive protective effect of CABG over time.

A number of studies reported on a possible increased risk of morbidity and mortality after coronary artery bypass grafting in patients with prior percutaneous coronary intervention. A systematic review and meta-analysis of studies comparing the outcome of patients undergoing coronary surgery with or without prior percutaneous coronary intervention was performed. Only studies reporting results of adjusted analysis and excluding acute percutaneous coronary intervention failures were included in this meta-analysis. Literature search yielded nine studies reporting on 68,645 patients who underwent coronary surgery. Of them, 8,358 (12.2%) had a prior percutaneous coronary intervention. Patients without prior percutaneous coronary intervention were significantly older (p=0.002), had significantly higher prevalence of left main stenosis (p=0.005) and three-vessel disease (p<0.0001). Prior percutaneous coronary intervention was associated with higher risk of resternotomy for bleeding (p=0.04) and dialysis (p=0.003). Thirty-day/in-hospital mortality was significantly higher in patients with prior percutaneous coronary intervention (pooled rate: 2.7% vs 2.0%, risk ratio 1.39, 95% confidence interval 1.06-1.84, p=0.02) as confirmed also by generic inverse variance analysis (risk ratio 1.47, 95% confidence interval 1.12-1.93, p=0.005). Prior percutaneous coronary intervention did not affect late outcome (five studies included, risk ratio 1.07, 95% confidence interval 0.90-1.28, p=0.43). Prior percutaneous coronary intervention seems to be associated with an increased risk of immediate postoperative morbidity and mortality after coronary surgery, but does not affect late mortality. These results are not conclusive and need to be confirmed by studies of better quality evaluating the impact of indication, timing, type of stents, amount of treated vessels and number of previous percutaneous coronary interventions.

Review of Case-Mix Corrected Survival Curves

BackgroundCoronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed.Methods and ResultsWe aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North‐Rhine‐Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in‐hospital all‐cause mortality and major adverse cardio‐cerebral event. Patients were 68±11 years of age, had 3‐vessel and left main‐stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non–ST‐segment–elevation myocardial infarction, and 23.5% in ST‐segment–elevation myocardial infarction. A history of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non–ST‐segment–elevation myocardial infarction, and 16.1% in ST‐segment–elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non–ST‐segment–elevation myocardial infarction and 17.2% in ST‐segment–elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In‐hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI <24 hours, and 14.1% with failed PCI (P<0.003). The in‐hospital major adverse cardio‐cerebral event rate was 16.4% without PCI, but 17.4% with prior PCI >24 hours, 25.6% with prior PCI <24 hours, and 41.3% with failed PCI (P=0.014). Multivariable logistic regression analysis showed prior PCI (P=0.039), as well as failed PCI (P=0.001) to be predictors for in‐hospital all‐cause mortality and major adverse cardio‐cerebral event.ConclusionsIn the current PCI era, immediately prior or failed PCI before coronary artery bypass grafting in acute coronary syndromes is associated with high perioperative risk, cardiogenic shock, and increased morbidity and mortality.

Minimally invasive coronary artery surgery: Robotic and nonrobotic minimally invasive direct coronary artery bypass techniques.

Relation of Major Depression to Survival After Coronary Artery Bypass Grafting

Introduction Women with high cardiovascular risk are often underdiagnosed and subsequently undertreated leading to higher mortality. The cardiac SPECT/CT is recommended for risk stratification of symptomatic patients with known coronary artery disease (CAD) if the localization and area of ischemia may influence the clinical decision making. In patients with previous myocardial infarction (MI) or frequently after percutaneous coronary intervention (PCI), exercise ECG test is considered sub-optimal, since the possibility of ischemia is higher, and MI often makes the ST segment response more difficult to assess. Purpose To analyze the accuracy of cardiac SPECT/CT for symptomatic women with known CAD, prior MI or PCI. Methods For women included in Latvian cardiac SPECT/CT registry the cardiac SPECT/CT was performed in a single University Hospital from 2018 till 2023. True myocardial perfusion defect was defined as area of ischemia ≥ 10% of the left ventricle myocardium. Patients with perfusion defect were analyzed according to prescribed treatment option. Results Totally 365 patients with previously known CAD were analyzed, of whom 318 (87.1%) have had prior PCI and 114 (31.2%) – prior MI. True myocardial perfusion defect was detected in 55 patients (15.1%). The patients without performed further diagnostic tests were excluded. In patient group with prior MI, the significant perfusion defect was detected in 25 (21.9%) cases and in 15 women (60.0% form all positive cardiac SPECT/CTs in this group) repeated PCI was performed. Of patients with prior PCI, the significant perfusion defect was detected in 47 (14.8%) cases and in 24 women (51.0% form all positive cardiac SPECT/CTs in this group) repeated PCI was performed. In patients without prior PCI or MI (n=47), but with intermediate stenosis in coronary arteries, the primary PCI was performed in 17 (36.2%) cases. Conclusion A non-invasive imaging test with cardiac SPECT/CT is recommended to assess perfusion defect in patients with new or worsening cardiac symptoms; as a follow-up after myocardial infarction; with undergone prior PCI or CABG and to evaluate the impact on perfusion of intermediate stenosis in epicardial coronary arteries. In patients with significant perfusion defect and non-obstructive new stenosis regardless of prior MI or PCI, the diagnosis of coronary microvascular dysfunction and / or vasospasm should be considered.

ObjectiveTo conduct a large-scale, single-centre retrospective cohort study to understand the impact of prior percutaneous coronary intervention (PCI) on long-term survival of patients who then undergo coronary artery bypass graft...

Background: There are increasing number of patients who are referred for coronary artery bypass grafting (CABG) after prior percutaneous coronary intervention (PCI). The intent here is to characterize the risk, if any, that is associated with PCI experience prior to CABG. Methodology and patients: 2358 consecutive patients underwent coronary artery bypass grafting between January 2008 to December 2013 at two tertiary cardiac centers in Middle East (one center in Egypt and one in Saudi Arabia) divided in 2 groups: 1st group-492 patients with Prior PCI to CABG (PPCABG), and the 2nd group-1866 patients underwent CABG without previous PCI (Native Vessel CABG-NVCABG). We chose the 2 groups with similar cardiac morbidities and extra cardiac co-morbidities. Results: Except for emergency cases, clopidogrel, statin use and the distribution of NYHA classification, the two groups were similar in terms of baseline demographic and pre-operative characteristics. Summarized intra-operative and post-operative data showed that PPCABG group had significantly higher cross clamp time, total bypass time, higher incidence of post-operative complications such as bleeding, renal impairment than NVCABG and also significant higher in-hospital mortality rate in PPCABG group than NVCABG group. Conclusion: Future re-interventions after PCI are common and both extent of disease and re-stenosis of stents are responsible for re-intervention. PCI prior to CABG increases morbidity post operatively and seem to have an independent factor in increasing mortality. So, in the best interest of the patient, proper consensus among cardiologists and cardiac surgeons must be reached before subjecting to PCI, especially in cases of multivessel coronary artery disease.

Objective:Although safety concerns still remain among patients undergoing unanticipated noncardiac surgery after prior percutaneous coronary intervention (PCI), it has not been directly compared with coronary artery bypass grafting (CABG). The objective of this study was to compare clinical outcomes after noncardiac surgery in patients with prior (>6 months) coronary revascularization by PCI or CABG.Methods:From February 2010 to December 2015, 413 patients with a history of coronary revascularization, scheduled for noncardiac surgery were identified. Patients were divided into PCI group and CABG group and postoperative clinical outcome was compared between 2 groups. The primary outcome was composite of all-cause death, myocardial infarction, and stroke in 1-year follow-up.Results:The 413 patients were divided according to prior coronary revascularization types: 236 (57.1%) into PCI and 177 (42.9%) into CABG group. In multivariate analysis within 1-year follow-up, there was no significant difference in clinical outcome which was composite of all-cause death, myocardial infarction, and stroke (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 0.76-2.93; P = .24). The same result was present in propensity-matched population analysis (HR: 1.43; 95% CI: 0.68-3.0; P = .34).Conclusions:In patients undergoing noncardiac surgery with prior coronary revascularization by PCI or CABG performed on an average of 42 months after PCI and 50 months after CABG, postoperative clinical outcome at 1-year follow-up is comparable.

Invited commentary

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes

The comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients in whom both procedures are feasible remains poorly understood. To compare the effectiveness of PCI and CABG in patients for whom coronary revascularization is clinically indicated. MEDLINE, EMBASE, and Cochrane databases (1966-2006); conference proceedings; and bibliographies of retrieved articles. Randomized, controlled trials (RCTs) reported in any language that compared clinical outcomes of PCI with those of CABG, and selected observational studies. Information was extracted on study design, sample characteristics, interventions, and clinical outcomes. The authors identified 23 RCTs in which 5019 patients were randomly assigned to PCI and 4944 patients were randomly assigned to CABG. The difference in survival after PCI or CABG was less than 1% over 10 years of follow-up. Survival did not differ between PCI and CABG for patients with diabetes in the 6 trials that reported on this subgroup. Procedure-related strokes were more common after CABG than after PCI (1.2% vs. 0.6%; risk difference, 0.6%; P = 0.002). Angina relief was greater after CABG than after PCI, with risk differences ranging from 5% to 8% at 1 to 5 years (P < 0.001). The absolute rates of angina relief at 5 years were 79% after PCI and 84% after CABG. Repeated revascularization was more common after PCI than after CABG (risk difference, 24% at 1 year and 33% at 5 years; P < 0.001); the absolute rates at 5 years were 46.1% after balloon angioplasty, 40.1% after PCI with stents, and 9.8% after CABG. In the observational studies, the CABG-PCI hazard ratio for death favored PCI among patients with the least severe disease and CABG among those with the most severe disease. The RCTs were conducted in leading centers in selected patients. The authors could not assess whether comparative outcomes vary according to clinical factors, such as extent of coronary disease, ejection fraction, or previous procedures. Only 1 small trial used drug-eluting stents. Compared with PCI, CABG was more effective in relieving angina and led to fewer repeated revascularizations but had a higher risk for procedural stroke. Survival to 10 years was similar for both procedures.

Percutaneous Coronary Intervention With a Drug-Eluting Stent Versus Coronary Artery Bypass Grafting in Patients Receiving Dialysis: A National Study From Taiwan