Consecutive Coronary Artery Bypass Grafting Research Articles

Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions.

Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.

Outcomes of 881 Consecutive Coronary Artery Bypass Graft Patients Using Heartstring Device.

One of the strategies to prevent stroke after coronary artery bypass grafting (CABG) may be the use of a device for proximal anastomosis without partial clamp of the ascending aorta. We retrospectively investigated early and late outcomes in consecutive 881 patients undergoing isolated CABG using Heartstring for proximal anastomosis from January 2008 to December 2022, to reveal the validity to use it. All patients underwent preoperative imaging workups to evaluate neurovascular atherosclerosis. The mean age of the patients was 68.9 years, 20% were female and 13% had previous history of stroke. CABG was on-pump beating heart (52.2%) or off-pump (47.8%) with a mean number of distal anastomoses of 3.38 ± 0.93, using 1.62 ± 0.53 Heartstring devices under different aortic manipulations. In-hospital mortality was 2.0% and perioperative stroke rate was 0.9%, none of them died during hospital stay. During the follow-up period of 70 ± 47 months, the overall actuarial survival rates were 86 and 66%, and major adverse cardiac and cerebrovascular events (MACCEs)-free rates were 86 and 70% at 5 and 10 years, respectively. On multivariable analysis, risk factors for late death included male, previous history of stroke, postoperative sternomediastinitis, late new-onset stroke, and MACCEs, but did not include the perioperative stroke. Low stroke rate, as low as 0.9%, after CABG using Heartstring for proximal anastomosis, although under a variety of aortic manipulations, may contribute to the improved long-term prognosis.

Non-infectious sternal dehiscence after coronary artery bypass surgery

IntroductionNon-infectious sternal dehiscence (NISD) is a known complication following coronary artery bypass grafting (CABG), with previous studies estimating an incidence of 0.4–1% of surgeries. We aimed to study the incidence of NISD together with short- and long-term outcomes in a whole-nation cohort of patients.Materials and methodsA retrospective study on consecutive CABG patients diagnosed with NISD at Landspitali from 2001 to 2020. Patients diagnosed with infectious mediastinitis (n = 20) were excluded. NISD patients were compared to patients with an intact sternum regarding patient demographics, cardiovascular risk factors, intra- and postoperative data, and estimated overall survival. The median follow-up was 9.5 years.ResultsTwenty out of 2280 eligible patients (0.88%) developed NISD, and the incidence did not change over the study period (p = 0.98). The median time of diagnosis was 12 days postoperatively (range, 4–240). All patients were re-operated using a Robicsek-rewiring technique, with two cases requiring a titanium plate for fixation. Patients with NISD were older, had a higher BMI and EuroSCORE II, lower LVEF, and more often had a history of COPD, MI, and diabetes compared to those without NISD. Length of stay was extended by 15 days for NISD patients, but short and long-term survival was not statistically different between the groups.ConclusionsThe incidence of NISD was low and in line with previous studies. Although the length of hospital stay was extended, both short- and long-term survival of NISD patients was not significantly different from patients with an intact sternum.

Comparison of traditional and upper thoracic epidural analgesia after off-pump coronary artery bypass graft surgery: A Quasi-experimental study.

Background and AimsSurgical trauma initiates changes in central and peripheral nervous systems that need to be treated therapeutically to facilitate postoperative pain. The quality of postoperative analgesia is expected to affect clinical outcomes positively. Albeit optimal pain relief following cardiac surgery is often complex, researchers have tried to explore several techniques other than conventional ones during the last decade to find a unique analgesic method for postcardiac surgical patients. This study aims to find a unique analgesic approach that maximizes patient satisfaction after off‐pump coronary artery bypass graft (OPCABG) surgery.MethodsThe current study will compare the analgesic effect of upper thoracic epidural analgesia (TEA) with conventional analgesia after OPCAB graft surgery. For this, we will use a Quasi‐experimental study design. Patients admitted for coronary artery bypass graft (CABG) surgery will be assigned into two groups. The control group (conventional) will receive intravenous opioids and nonsteroidal anti‐inflammatory medications, and the study (case) group (TEA) will receive Inj. Bupivacaine 0.25% as an infusion through the epidural catheter. Physiologic parameters like hemodynamic and respiratory variables and pain scores will be recorded in predesigned format periodically.ResultsWe expect to analyze a total of 130 consecutive off‐pump CABG surgery patients in Group A (Case, 65 patients) and Group B (Control, 65 patients). Study variables will be the visual analog scale score, hemodynamic parameters (heart rate, mean arterial pressure, and respiratory parameters (respiratory rate, PaO2, PaCO2, PEFR, FEV1). After data collection, the result will be analyzed and published in the public domain and in journals.ConclusionWe expect thoracic epidural analgesia with local anesthetics will be a reliable postoperative analgesic option.

Resternotomy Coronary Artery Bypass 1999-2018: Insights From The Society of Thoracic Surgeons Adult Cardiac Surgery Database

BackgroundWe sought to quantify the risk trend of resternotomy coronary artery bypass grafting (CABG) over the past 2 decades. MethodsWe compared the outcomes of 194 804 consecutive resternotomy CABG patients and 1 445 894 randomly selected first-time CABG patients (50% of total) reported to The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 1999 and 2018. Primary outcomes were in-hospital mortality and overall morbidity. Using multiple logistic regression for each outcome for each year, we computed the annual trends of risk-adjusted odds ratios for the primary outcomes in the entire cohort and in 194 776 propensity-matched pairs. ResultsThe annual resternotomy CABG case volume from participating centers declined by 68%, from a median of 25 (range, 14-44) to a median of 8 (range, 4-15). Compared with first-time CABG, resternotomy CABG patients were consistently older, with higher proportions of comorbidities. After propensity matching, primary outcomes of resternotomy and first-time CABG were similar (mortality: 3.5% vs 2.3%, standardized difference [SDiff], 7.5%; morbidity: 40.7% vs 40.3%, SDiff, 0.9%). Mortality of resternotomy CABG performed after prior CABG was higher than that after prior non-CABG (4.3% vs 2.4%; SDiff, 10.8). Morbidity was similar between these subgroups (41.0% vs 39.1%; SDiff, 2.9). The adjusted odds ratio for mortality after resternotomy CABG declined from 1.93 (95% CI, 1.73-2.16) to 1.22 (95% CI, 0.92-1.62), and that of morbidity declined from 1.13 (95% CI, 1.08-1.18) to 0.91 (95% CI, 0.87-0.95), P < .001 for both. ConclusionsThe risk of resternotomy CABG has decreased substantially over time. Resternotomy CABG performed after a prior CABG is higher risk compared with that performed after a non-CABG operation.

Vascular Access-Site Choice and Outcomes in Patients With Previous Coronary Artery Bypass Surgery Undergoing Coronary Catheterization in a High-Volume Transradial Center.

Transradial access for coronary angiography was observed to be superior to femoral access. Nevertheless, femoral artery access is still frequently used, especially in challenging subgroups with high procedural complexity, like patients with previous coronary artery bypass grafting (CABG). We analyzed access-site choice and outcomes of CABG patients undergoing coronary catheterization in different clinical settings. A total of 1206 consecutive CABG patients undergoing coronary angiography and intervention were included in this study. Procedural and clinical outcomes were compared between transradial and transfemoral access. Multivariate logistic regression analysis was performed to identify predictors of access-site choice. Coronary catheterization was performed via radial access in 753 patients (63.1%) and via femoral access in 442 patients (36.9%). During the study period, femoral artery utilization dropped from 55.2% to a minimum of 28.2% per year (P<.01). Short stature (odds ratio [OR], 1.62; P<.01), peripheral artery disease (OR, 1.42; P=.04), cardiopulmonary resuscitation (CPR) (OR, 4.17; P<.001), ST-segment elevation myocardial infarction (STEMI) (OR, 2.56; P=.01), and coexisting left and right internal mammary artery (LIMA/RIMA) bypass grafts (OR, 2.67; P<.001) were independently associated with femoral access-site choice. Study outcomes including access-site complications (4.3% vs 1.6%; P<.01) as well as short- and long-term mortality (30-day mortality: 6.8% vs 2.0%; hazard ratio, 3.52; 95% confidence interval, 1.84-6.70; P<.001) were more likely to occur with femoral access. Length of stay was shorter in the radial cohort (3.7 ± 5.1 days vs 5.3 ± 7.2 days; P<.001). Radial access appears to be favorable even in complex CABG patients. Although radial access was set as the standard vascular approach, femoral access was chosen in one-third of all patients. Independent predictors for femoral access were short stature, peripheral artery disease, acute settings like CPR and STEMI, as well as coexisting LIMA and RIMA grafts.

Prognostic value of vasodilator stress perfusion CMR in patients with previous coronary artery bypass graft.

The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are established in coronary artery disease (CAD) patients. Because myocardial contrast kinetics may be altered after coronary artery bypass graft (CABG), most studies excluded CABG patients. This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in CABG patients. Consecutive CABG patients referred for stress CMR were retrospectively included and followed for the occurrence of major adverse cardiovascular events (MACE) including cardiovascular (CV) death or non-fatal myocardial infarction (MI). Cox regression analyses were performed to determine the prognostic association of inducible ischaemia and late gadolinium enhancement (LGE) by CMR. Of 866 consecutive CABG patients, 852 underwent the stress CMR protocol and 771 (89%) completed the follow-up [median (interquartile range) 4.2 (3.3-6.2) years]. There were 85 MACE (63 CV deaths and 22 non-fatal MI). Using Kaplan-Meier analysis, the presence of inducible ischaemia identified the occurrence of MACE [hazard ratio (HR) 3.52, 95% confidence interval (CI): 2.27-5.48; P < 0.001] and CV death (HR 2.55, 95% CI: 1.52-4.25; P < 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 3.22, 95% CI: 2.06-5.02; P < 0.001) and CV death (HR 2.15, 95% CI: 1.28-3.62; P = 0.003), and the same was observed for LGE (both P = 0.02). Stress CMR has a good discriminative prognostic value in patients after CABG, with a higher incidence of MACE and CV death in patients with inducible ischaemia and/or LGE.

Multicenter experience: early outcome of mitral valve repair in patients with ischemic mitral regurgitation

Ischemic mitral regurgitation is associated with poor outcomes. The optimal surgical strategy for management of ischemic mitral regurgitation is still debated. The objective of this study was to evaluate the early mortality and morbidity of mitral valve repair in patients with ischemic mitral regurgitation undergoing coronary artery bypass grafting. We performed a retrospective, observational, cohort study on prospectively collected data on 136 consecutive coronary artery bypass graft patients with ischemic mitral regurgitation undergoing mitral valve repair between January 2016 and January 2020. Perioperative echocardiogram findings, operative procedures, and outcomes were analyzed. The overall mortality rate was 4.4%. Mitral valve repair with a low ejection fraction had a 4-fold increase in the risk of death compared to mitral valve repair with preserved ejection fraction > 30%. However, after adjusting for preoperative risk factors, the number of grafts was not an independent risk factor for mortality (odds ratio = 0.18, 95% confidence interval: 0.03-2.81, p = 0.84). Multivariable analysis showed that preoperative ejection fraction (odds ratio = 1.14, 95% confidence interval: 0.82-4.86, p < 0.01), preoperative left ventricular end-systolic dimension (odds ratio = 1.03, 95% confidence interval: 0.65-3.51, p < 0.01) and preoperative left ventricular end-diastolic dimension (odds ratio = 0.99, 95% confidence interval: 0.64-3.28, p = 0.04) were independent risk factors for mortality. Mitral valve repair can be performed safely concomitantly with coronary artery bypass grafting in patients with moderate, moderately severe, and severe ischemic mitral regurgitation.

A Novel Risk Stratification System for Predicting In-Hospital Mortality Following Coronary Artery Bypass Grafting Surgery with Impaired Left Ventricular Ejection Fraction.

Coronary artery disease (CAD) is the most common cause of heart failure (HF), and impaired ejection fraction (EF<50%) is a crucial precursor to HF. Coronary artery bypass grafting (CABG) is an effective surgical solution to CAD-related HF. In light of the high risk of cardiac surgery, appropriate scores for groups of patients are of great importance. We aimed to establish a novel score to predict in-hospital mortality for impaired EF patients undergoing CABG. Clinical information of 1,976 consecutive CABG patients with EF<50% was collected from January 2012 to December 2017. A novel system was developed using the logistic regression model to predict in-hospital mortality among patients with EF<50% who were to undergo CABG. The scoring system was named PGLANCE, which is short for seven identified risk factors, including previous cardiac surgery, gender, load of surgery, aortic surgery, NYHA stage, creatinine, and EF. AUC statistic was used to test discrimination of the model, and the calibration of this model was assessed by the Hosmer-lemeshow (HL) statistic. We also evaluated the applicability of PGLANCE to predict in-hospital mortality by comparing the 95% CI of expected mortality to the observed one. Results were compared with the European Risk System in Cardiac Operations (EuroSCORE), EuroSCORE II, and Sino System for Coronary Operative Risk Evaluation (SinoSCORE). By comparing with EuroSCORE, EuroSCORE II and SinoSCORE, PGLANCE was well calibrated (HL P = 0.311) and demonstrated powerful discrimination (AUC=0.846) in prediction of in-hospital mortality among impaired EF CABG patients. Furthermore, the 95% CI of mortality estimated by PGLANCE was closest to the observed value. PGLANCE is better with predicting in-hospital mortality than EuroSCORE, EuroSCORE II, and SinoSCORE for Chinese impaired EF CABG patients.

Single Endothelial Cell mRNA Sequencing Better Captures the Severity of Coronary Artery Disease Than Targeted Total Arterial Markers of Inflammation and Senescence

Endothelial dysfunction is the initial step towards atherosclerotic plaque development and coronary artery disease (CAD). Senescent endothelial cells (SnEC) have been linked to the atherosclerotic burden. In particular, the senescent‐associated secretory phenotype protein angiopoietin‐like 2 (ANGPTL2) was shown to be elevated in the plasma of CAD patients and related to the senescent cellular load in human internal mammary artery (IMA) segments discarded during coronary artery bypass grafting (CABG) surgery. We tested the hypothesis that the accumulation of vascular SnEC causes endothelial dysfunction and precedes the appearance of atherosclerotic lesions.Discarded atheroma‐free IMA segments from 12 patients (11 men and 1 woman, 69±3 years) were collected during consecutive elective CABG surgeries. Arterial rings of IMA segments were mounted in a wire myograph to record isometric changes in tension: arteries were pre‐contracted with U46619, a synthetic analogue of PGH2, and endothelium‐dependent relaxations to increasing concentrations of acetylcholine (ACh) were recorded. The maximal relaxation (Emax) and the concentration of ACh inducing 50% of relaxation (EC50) were calculated. Afterwards total mRNA was extracted from the IMA segments. Vascular gene expression of ANGPTL2 and p21 (senescence markers), and CD68 and PAI‐1 (inflammatory markers) were assessed by RT‐qPCR. In parallel, single‐cell RNA sequencing was performed in IMA segments from two age‐matched male patients obtained either during elective (stable CAD) or emergency (unstable CAD, with numerous risk factors) procedures, and differential gene expression was specifically analyzed in vascular EC.Endothelium‐dependent relaxations were characterized by Emax (56±7 %, [18–100%], n=12) and pD2 (‐log EC50: 6.9±0.1 [5.8–7.3], n=12). Patients were divided into 2 groups according to their Emax (&lt; or &gt; to 50%) to define low and high endothelial function; vascular gene expression of the 4 senescence and inflammatory markers were similar between the two groups, demonstrating that global arterial wall senescence and inflammation did not distinguish severity of endothelial dysfunction. We then used single‐cell mRNA sequencing and analysed the unbiased differential gene expression specifically in vascular EC. From the total IMA cellular counts, EC represented ~2%. Nine genes were identified that were differentially overexpressed in EC from unstable CAD patient that have been associated with senolytic drug targets and cardiovascular diseases (Table ), potentially attesting to the severity of endothelial dysfunction and CAD.In conclusion, unlike total arterial wall mRNA quantification, unbiased single‐cell mRNA sequencing identified differentially upregulated endothelial pathways that may contribute to the severity of the CAD by inducing precocious endothelial dysfunction and senescence. Top genes differentially expressed in endothelial cells between a stable and unstable CAD patient. Percentages represent the percent of endothelial cells expressing the gene in each patient dataset. P‐values are Bonferroni corrected. Stable CAD patient Unstable CAD patient p‐value Gene Associated CVD disorder or drug target 0.0% 41.7% 0.00061 TGFB2 Atrial fibrillation 0.0% 41.7% 0.00061 SQLE Statins 2.9% 58.3% 0.00090 RPPH1 Quercetin (senolytic drug) 7.1% 66.7% 0.00339 ARL14EP Systolic blood pressure 25.7% 100.0% 0.00914 RPL17 Myocardial ischemia 17.1% 83.3% 0.01556 IGFBP7 Ruptured aneurysm 0.0% 33.3% 0.01699 TMEM8B Heart valve disorders 0.0% 33.3% 0.01699 ZNF675 Congestive heart failure 8.6% 66.7% 0.04848 SELL Vaso‐occlusive crisis

Hyperoxemia reduces cerebrovascular accidents post coronary artery bypass graft surgery: a retrospective cohort study

Cerebrovascular accidents (CVAs) including strokes and transient ischaemic attacks (TIAs) form a major portion of perioperative morbidity in patients undergoing coronary artery bypass graft (CABG) surgery. The aim of this article was to: (I) to examine the relationship between providing increased intraoperative partial pressure of arterial oxygen (PaO 2 ) and the risk of perioperative CVA following CABG surgery; (II) to examine the relationship between intraoperative PaO 2 and other perioperative adverse outcomes. This was a retrospective cohort study involving 2,253 consecutive CABG patients located within a single cardiothoracic unit of a tertiary hospital. All patients underwent CABG surgery. A multivariate analysis was undertaken to assess the relationship between the PaO 2 (intra-operative mean and nadir) and its associated risk of perioperative CVA. Results were reported as odds ratios (OR) with 95% confidence interval (95% CI). There was a significant (but clinically limited) inverse correlation between average intra-operative PaO 2 and reducing peri-operative CVA (OR 0.99; P=0.029; 95% CI: 0.98–1.00), indicating a reduction in stroke risk with increasing PaO 2 . There was no significant association with PaO 2 nadir and CVA. There was no significant association between increasing hyperoxia and the following adverse events: pneumonia, prolonged postoperative ventilation, perioperative myocardial infarction or cardiac arrest, sternal wound infection, sepsis and renal failure. We report a significant inverse correlation between increasing average intra-operative PaO 2 and reducing peri-operative CVA. Further, hyperoxia was not associated with any adverse effects or infective outcomes. This finding is likely to have preventative and therapeutic implications through reducing stroke risk.

D-dimer Düzeyi Koroner Arter Baypas Cerrahisinden Sonra İskemi/Reperfüzyon Hasarının Bir Bulgusudur

Introduction: Myocardial Ischaemia-Reperfusion (I-R) injury produces a spectrum of clinical cardiovascular outcomes after cardiac surgery. The pathogenesis of I-R injury is complex and involves the activation and amplification of several systemic and local proinflammatory pathways. The process of restoring blood flow to the ischaemic myocardium can induce injury and paradoxically reduce the beneficial effects of myocardial reperfusion. The objective of this study was to determine the correlation between cardiac markers such as the Mb fraction of the creatine kinase (CK-MB), troponin I (cTnI) and D-dimer levels as a marker of myocardial injury secondary to I-R injury after coronary artery bypass surgery. Patients and Methods: Herein, a prospective study was designed that included 50 consecutive coronary artery bypass grafting (CABG) patients. Pre and postoperative blood samples were taken due to study protocol and such markers as Mb fraction of the creatine kinase (CK-MB), troponin I (cTnI) and D-dimer were measured. Results: All three markers were significantly elevated in postoperative blood samples. The D-dimer level reached its peak at the first and another peak at 12th hour postoperatively. However, the peak serum values of CK-MB and cTnI occurred at 6th and 12th hour, respectively. Conclusion: We demonstrated that D-dimer levels as a marker of generated thrombin during reperfusion correlated with other well-known biochemical markers of myocardial damage in the postoperative period. In other words, D-dimer levels may stand as a marker of I-R-induced myocardial damage.

Clinical significance of presenting syndromes on outcome after coronary artery bypass grafting.

Evidence of an association between postoperative survival and the presenting syndrome following coronary artery bypass grafting (CABG) is limited. Our goal was to evaluate whether the presenting symptoms of acute coronary syndrome (ACS) or stable ischaemic heart disease were associated with mid-term survival in patients undergoing CABG. We performed a single-centre retrospective study involving consecutive CABG operations from 2011 to 2016. Post-discharge survival was ascertained via patient-level data linkage with the State of Connecticut vital statistics. Baseline and postoperative variables were compared between the two groups. The multivariate Cox proportional hazard model, adjusted for demographics and comorbidity, was used to show whether the presenting syndrome category was independently associated with mid-term survival. A total of 1631 patients were included: 794 with stable ischaemic heart disease and 837 with ACS. Patients with ACS who underwent CABG showed more comorbidities. The overall 30-day mortality rate was 1.8% (ACS 2.3% vs stable ischaemic heart disease 1.3%; P = 0.12). In-hospital, postoperative outcomes revealed higher rates of prolonged ventilation (11.7% vs 4.8%; P < 0.001), pneumonia (6.6% vs 3.9%; P = 0.016) and stay in the intensive care unit (3.7 ± 4.0 vs 3.2 ± 2.7 days; P = 0.014) in patients with ACS. The overall mean duration of the long-term follow-up period was 27.9 ± 16.5 months, during which 117 deaths occurred. The multivariable Cox proportional hazard model adjusted for demographics and comorbidity showed that ACS was not a predictor of mid-term mortality [hazard ratio (HR) 1.26, 95% confidence interval (CI) 0.84-1.90; P = 0.26]. Other significant predictors were cardiogenic shock (HR 2.12, 95% CI 1.04-4.33; P = 0.039) and history of congestive heart failure (HR 1.78, 95% CI 1.18-2.69; P = 0.0062). The presenting syndrome was not an independent predictor of the mid-term mortality rate. The results indicate that the classification of the presenting syndrome may be fluid and that clinical decision-making for postoperative care of patients who have CABG directed by category of presenting syndrome needs careful consideration. These data should be interpreted in the context of the limitations of this study.

Long Term Outcomes of The Off-Pump and On-Pump Coronary Artery Bypass Grafting In A High-Volume Center

Coronary artery bypass grafting (CABG) remains the most frequent surgery in the practice of an adult cardiac surgeon and the most frequently performed cardiac surgical procedure worldwide. Despite the ongoing debates regarding the superiority or inferiority of off-pump coronary artery bypass grafting, it still comprises 15–30% of all CABG cases varying in different national registries. We performed a propensity matched study of 302 consecutive CABG patients,143 off -pump cases performed by the four experienced off-pump surgeons and the on-pump CABG cases performed by those surgeons and four other experienced coronary surgeons. The five year follow up was performed and data collected comprised of mortality, rehospitalization due to cardiac origin, repeated revascularization, myocardial infarction and cerebrovascular accident. Overall, the off-pump group of patients had a higher risk profile than the patients in the on-pump group. After matching, fewer differences were found between the groups. Propensity score matching analysis showed no difference in long-term survival as well as MACCE and repeated revascularization. The higher risk profile of the patients subjected to OPCAB and the comparable survival to lower risk CPB patients in this series indicate that in experienced hands, OPCAB is a valuable option in this important subgroup of patients.

Comparison of intestinal ischemia after on-pump versus off-pump coronary artery bypass grafting surgery

Background/aim Acute mesenteric ischemia (AMI), one of the gastrointestinal system complications, which occurs following cardiac surgery, is challenged in the literature with a diminished incidence of AMI by heart surgery without cardiopulmonary bypass (CPB) or with pulsatile CPB. This study aims to compare the incidence and mortality rate of mesenteric ischemia in a series of consecutive patients undergoing coronary artery bypass grafting (CABG) through on-pump and off-pump techniques.Materials and methods This study included patients who underwent CABG between 1 January 2010 and 31 June 2016. All patients were divided into two groups: Group 1 comprised 6396 CABG patients operated on with the off-pump technique. Group 2 included 1210 patients who received CABG with the on-pump technique. Preoperative data were collected on the studied variables. Postoperative data included the development of intestinal ischemia and in-hospital mortality.Results Of 7606 consecutive CABG patients, a total of 31 (0.4%) developed intestinal ischemia. The incidence of postoperative mesenteric ischemia was 0.28% in Group 1 and 1.07% in Group 2 (P = 0.000). The survival rates after AMI were 61.1% in Group 1 (off-pump) and 7.7% in Group 2 (on-pump) (P = 0.003). Time from the first occurrence of nonspecific GI complaints to laparotomy was similar in the off-pump and on-pump groups and had no effect on mortality.Conclusions: With regard to the incidence of mesenteric ischemia and survival after laparotomy, off-pump CABG patients revealed significant improvement compared with those operated on with the on-pump technique.

Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score

BackgroundPrediction scoring systems for coronary artery bypass grafting (CABG) patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) have not yet been reported. This study was designed to develop a predictive score for in-hospital mortality for cardiogenic shock patients who received VA-ECMO after isolated CABG.MethodsRetrospective cohort study of consecutive CABG patients supported with VA-ECMO (n = 166) at the Beijing Anzhen Hospital between February 2004 and March 2017.ResultsOne hundred and six patients (64%) could be weaned from VA-ECMO, and 74 patients (45%) survived to hospital discharge. On the basis of multivariable logistic regression analyses, the pRedicting mortality in patients undergoing veno-arterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score was created with six pre-ECMO parameters: older age, left main coronary artery disease, inotropic score > 75, CK-MB > 130 IU/L, serum creatinine > 150 umol/L, and platelet count < 100 × 109/L. Four risk classes, namely class I (REMEMBER score 0–13), class II (14–19), class III (20–25), and class IV (> 25) with their corresponding mortality (13%, 55%, 70%, and 94%, respectively), were identified. The area under the receiver operating characteristic curve 0.85(95% CI 0.79–0.91) for the REMEMBER score was better than those for the SOFA, SAVE, EuroSCORE, and ENCOURAGE scores in this population.ConclusionsThe REMEMBER score might help clinicians at bedside to predict in-hospital mortality for patients receiving VA-ECMO after isolated CABG for refractory cardiogenic shock. Prospective studies are needed to externally validate this scoring system.

Long-term impact of critical silent cerebrovascular disease in patients undergoing coronary artery bypass surgery: a propensity score and multivariate analyses.

Cerebrovascular disease (CVD) with brain hypoperfusion is a strong risk factor for stroke. However, how this pathology influences long-term outcomes after coronary artery bypass graft (CABG) surgery is not known. Magnetic resonance imaging/angiography (MRI/A) of the neck and brain was performed in 318 out of 575 consecutive CABG patients between May 2005 and April 2018. Critical CVD with chronic hypoperfusion was defined as multiple severe stenoses (⩾70%) and/or occlusion in the carotid and/or vertebral systems associated with reduced collateral flow due to severe contralateral and/or circle of Willis lesion. Fifty patients were identified to have this pathology (early results were previously reported). The entire cohort was followed up for 83.6 ± 53.7 months. Carotid endarterectomy was considered for symptomatic patients. Propensity matching was performed to compare long-term outcomes between patients with and without critical CVD. Patients with critical CVD at follow-up displayed significantly higher incidences of stroke than those without critical CVD (p=0.007), with an extremely high final incidence (approximately 40% at 8 years). However, survival (p=0.623) and incidences of major adverse cardiac events (MACE: myocardial infarction, coronary revascularization and all causes of death) (p=0.881) were similar. The Cox hazard model revealed that critical CVD was the strongest risk factor for stroke (p=0.000; hazard ratio 6.572; 95% confidence interval 2.657-16.258) while not affecting survival and MACE. Critical CVD was the strongest risk factor for long-term stroke after CABG. However, survival and MACE-free rates were equivalent in patients with critical CVD and those without critical CVD.

Surgical Atrial Fibrillation Ablation Improves Long-Term Survival: A Multicenter Analysis

The Society of Thoracic Surgeons guidelines recommend surgical ablation (SA) at the time of concomitant mitral operations, aortic valve replacement, coronary artery bypass grafting (CABG), and aortic valve replacement plus CABG for patients in atrial fibrillation (AF). The goal of this analysis was to assess the influence of SA on long-term survival. A retrospective analysis of 20,407 consecutive CABG or valve procedures from 2008 to 2015 among seven centers reporting to a prospectively maintained clinical registry was conducted. Patients undergoing operation with documented preoperative AF were included (n= 2,740). Patients receiving SA were compared with patients receiving no SA. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity and mortality. The frequency of SA was 23.1% (n= 634), and an increase was seen in the rate of SA over the study period (p < 0.001). Concomitant SA was performed in 16.2% of CABG, 30.6% of valve, and 24.3% of valve plus CABG procedures. A substantial improvement was found in unadjusted survival among patients undergoing SA (hazard ratio 0.54, 95% confidence interval: 0.42 to 0.70). Moreover, no differences were found in postoperative complications. SA did have longer bypass times (p < 0.001) but a shorter overall length of stay (p<0.001). After risk adjustment, SA patients had an improved 5-year survival (hazard ratio 0.69, 95% confidence interval: 0.51 to 0.92), and the effect was observed across all operations. In a multicenter cohort of patients with AF, concomitant SA resulted in substantially improved long-term survival across patients who underwent CABG, valve, and valve plus CABG. These findings support current guidelines from The Society of Thoracic Surgeons that recommend broader application of concomitant SA.

Adverse Cerebral Outcomes after Coronary Artery Bypass Surgery-More Than a Decade of Experience in a Single Center.

Nonfatal strokes, transient ischemic attacks (TIAs), and reversible ischemic neurological deficits (RIND) after elective coronary artery bypass grafting (CABG) are devastating clinical problems. The anesthesiologist, surgical and intensive care teams in a community hospital adopted a strategy developed in an effort to minimize these adverse outcome events.The purpose of this study is to determine the incidence of and predictors for perioperative adverse neurologic events. A historical cohort study of 1,108 consecutive CABG patients operated between 2002 and 2014. Outcomes were defined as (1) a new neurologic damage (a new stroke, TIA, or RIND) and (2) a new neurologic damage or 30 days mortality. Adverse cerebral outcomes occurred in 16 patients (1.4 percent). Nine patients had postoperative stroke, six suffered TIAs, and one had postoperative RIND.In multivariate analysis, older age (OR 1.07, 95% CI 1.01-1.14), congestive heart failure (OR 3.57, 95% CI 1.22-10.49) and prior stroke (OR 6.27, 95% CI 1.78-22.03) were significantly associated with increased risk of new neurologic damage. These parameters were also significantly associated with increased risk of the combined outcome (new neurologic damage/mortality). A low incidence rate of adverse cerebral outcomes after CABG in community hospital can be achieved with the use of the suggested surgical intensive care, and anesthetic strategy. Advanced age, congestive heart failure, and prior stroke are associated with adverse outcomes.

Should Diabetes Be a Contraindication to Bilateral Internal Mammary Artery Grafting?

This study evaluates the influence of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting on postoperative morbidity and long-term survival among diabetic patients undergoing coronary artery bypass grafting (CABG). A multicenter, retrospective analysis of 47,984 consecutive CABGs performed from 1992 to 2014 at 7 medical centers was conducted. Among the study population, 1,482 CABGs with BIMA were identified, and 1,297 BIMA patients were propensity-matched to 1,297 SIMA patients. The study cohort for this analysis, drawn from matched data, included 430 diabetic patients: 217 SIMA and 213 BIMA. The primary endpoint was long-term survival. Secondary endpoints included postoperative morbidity, length of stay, and in-hospital mortality. The median duration of follow-up was 9.3 (range, 4.3 to 13.9) years. Among propensity-matched diabetic patients, there was no significant difference in age, body mass index, or major baseline comorbidities. The groups were also well matched on the number of diseased coronary arteries and number of distal anastomoses performed. There was no difference in the rate of mediastinitis or sternal dehiscence (p= 0.503) or in-hospital mortality (p= 0.758) between groups. Both groups had a similar median length of stay of 5 (range, 4 to 7) days. Diabetic patients who received a BIMA had significantly improved long-term survival when compared with SIMA patients (hazard ratio 0.75 [95% confidence interval 0.57 to 0.98], p= 0.034). Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently.