Conventional Coronary Artery Bypass Grafting Research Articles

Total coronary revascularization via left anterior thoracotomy: Comparison of early- and mid-term results with conventional surgery

Background: This study aimed to evaluate the efficacy and safety of total coronary revascularization via left anterior thoracotomy (TCRAT) by comparing it to conventional coronary artery bypass grafting (CABG) with median sternotomy. Methods: In this retrospective study, 108 patients (95 males, 13 females; mean age: 57.1±8.8; range, 41 to 75 years) who underwent TCRAT (Group 1) and 154 patients (126 males, 28 females; mean age: 61.2±9.8; range, 31 to 79) who underwent conventional CABG (Group 2) between February 1, 2021, and September 1, 2022, were evaluated. The operations were performed by the same surgical team. Preoperative, operative, and postoperative data of patients and mid-term follow-up data were analyzed. Results: Mean cardiopulmonary bypass and cross-clamp times, respectively, were 167.70±68.93 and 77.03±38.18 min in Group 1 and 106.64±38.27 and 62.21±24.06 min in Group 2 (p<0.001). During the postoperative period, the all-cause mortality rate was 5.8% (n=9) in Group 2, while it was 0.9% (n=1) in Group 1; there was a statistically significant difference between the two groups (p=0.037). Nevertheless, the mean preoperative EuroSCORE (European System for Cardiac Operative Risk Evaluation) II was 2.59±2.3 in Group 2, which was significantly higher than the mean EuroSCORE II of Group 1 (1.37±1.5; p<0.001). The mean hospitalization duration for Group 2 was 6.99±3.37 days, and the mean hospitalization duration for Group 1 was 6.77±4.24 days. Duration of hospitalization was statistically significantly shorter in Group 1 (p=0.047). In addition, the mean perioperative number of erythrocyte suspension transfusions in Group 1 was 1.51±1.74, while it was 1.86±1.75 in Group 2. Significantly fewer erythrocyte suspension transfusions were performed in Group 1 (p=0.033). Conclusion: The findings of our study indicate that TCRAT is a safe and viable technique when performed on a select patient group compared to the conventional method.

Spontaneous avulsion of left internal mammary artery graft a complication of coronary artery bypass surgery: case report and review of the literature

BackgroundCoronary artery bypass grafting (CABG) surgery is a common procedure for managing multi-vessel coronary artery disease to revascularize the myocardium. Among the various conduits used, the left internal mammary artery (LIMA) is preferred due to its better long-term patency rate. However, CABG procedures involving LIMA may result in rare but serious complications, such as avulsion of the LIMA post-CABG, which leads to disruption of blood flow to the myocardium and the development of fatal cardiac tamponade.Case presentationWe hereby present a unique case of spontaneous avulsion of a LIMA graft to the left anterior descending artery (LAD) away from the site of anastomosis, twenty-four hours following CABG surgery in a 67-year-old male patient. Emergency re-exploration and repair of the LIMA with interposition vein graft were performed and resulted in successful stabilization of the patient’s critical condition. However, this was followed by a complicated recovery period involving atrial fibrillation, acute kidney injury, and wound infection.ConclusionAvulsion of LIMA graft following CABG is rare, yet a fatal complication that requires high clinical suspicion and prompt management. Avulsion has been reported a few times in literature following both minimal invasive and conventional CABG. Understanding the etiology, clinical presentation, and management of this complication is crucial to avoid catastrophic outcomes.

Total Arterial Multivessel Minimally Invasive Coronary Artery Bypass Surgery: 5-Year Outcomes

BackgroundTotal arterial revascularization is associated with superior outcomes to conventional coronary artery bypass graft (CABG) surgery performed with the left internal thoracic artery (ITA) and veins. It is often performed with bilateral ITAs that increase risk of sternal wound infection. Minimally invasive multivessel CABG through a left anterior minithoracotomy eliminates sternal wound complications. However, being performed only in a few specialized centers, there is a paucity in follow-up outcome data. We, therefore, describe our 5-year single-center experience with such operations. MethodsBetween 2015 and 2021, 186 patients underwent elective, total arterial minimally invasive CABG in our institution. Patient data were prospectively collected in the institutional database and retrospectively analyzed. Primary end points were in-hospital mortality and 5-year survival. The secondary end points included freedom from major adverse cerebrovascular and cardiac events. ResultsPatients were a mean age of 66 ± 9 years, and 23 (12%) were women. The mean number of bypass grafts performed was 2.4 ± 0.5 (range, 2-4 grafts). Bilateral ITAs were used in 163 patients (88%) and left ITA and radial arteries in 22 (12%). The mean procedure time was 277 ± 58 minutes. There was 1 hospital death. Perioperative myocardial infarction, repeat thoracotomy, and conversion to sternotomy was observed in 6 (3%), 12 (6.5%), and 2 patients (1.1%), respectively. The mean 5-year survival was 93.3% ± 2.2%, and freedom from major adverse cardiac and cerebrovascular events was 83.8% ± 4.1%. ConclusionsTotal arterial minimally invasive CABG is a feasible surgical approach yielding excellent short- and midterm results when performed in selected patients in specialized high-volume cardiac centers.

Very Delayed Surgical Bleeding after Coronary Artery Bypass Graft Causing Cardiac Tamponade and Cardiogenic Shock: A Rare Case Report

Delayed surgical bleeding from the left internal mammary artery (LIMA) bed following coronary artery bypass grafting (CABG) is a rare yet potentially fatal condition that can lead to cardiac tamponade and life-threatening cardiogenic shock. We present a case of extremely delayed active bleeding from the LIMA bed, occurring 5 weeks after conventional CABG, resulting in cardiac tamponade and cardiogenic shock. The 73-year-old patient presented to the emergency room with a 2-day history of general weakness and hypotension. He had undergone CABG 5 weeks ago. Optimal inotropic agents and vasopressors were used for the treatment of shock. In the emergency room, real-time bedside echocardiography showed severe external compression of the right ventricle by a homogeneous, hyperechoic mass. Veno-arterial (V-A) mode extracorporeal membrane oxygenation (ECMO) was promptly instituted to stabilize hemodynamics. Subsequent chest re-exploration, involving blood clot evacuation, was performed, and the bleed from the distal LIMA bed was ligated. Delayed LIMA bed bleeding causing cardiac tamponade and cardiogenic shock is an infrequent occurrence, and the use of V-A mode ECMO successfully provided a window of time for chest exploration.

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.

Minimally Invasive Coronary Artery Bypass Grafting in a Low-Risk Asian Cohort: A Propensity-Score Matched Study.

Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new paradigm in coronary revascularization. This study aims to compare the outcomes of MICS CABG with those of conventional median sternotomy CABG (MS CABG) within a growing minimally invasive cardiac surgical program in Singapore. Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2). Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups. MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.

Comparative analysis of del Nido cardioplegia versus blood cardioplegia in isolate coronary artery bypass grafting

BackgroundThis study examined the efficacy of del Nido cardioplegia compared with traditional blood cardioplegia in adult cardiac surgery for isolated coronary artery bypass grafting by evaluating the early postoperative outcomes.MethodsA total of 119 patients who underwent isolated conventional coronary artery bypass grafting were enrolled and divided into two groups (del Nido cardioplegia group [n = 36] and blood cardioplegia group [n = 50]) based on the type of cardioplegia used. This study compared the preoperative characteristics, intraoperative data, and early postoperative outcomes. Further subgroup analyses were conducted for high-risk patient groups.ResultsThe 30-day mortality and morbidity rates were not significantly different between groups. The del Nido cardioplegia group exhibited advantageous myocardial protection outcomes, demonstrated by a significantly smaller rise in Troponin I levels post-surgery (2.8 [-0.4; 4.2] vs. 4.5 [2.9; 7.4] ng/mL, p = 0.004) and fewer defibrillation attempts during weaning off of cardiopulmonary bypass (0.0 ± 0.2 vs. 0.4 ± 1.1 times, p = 0.011) when compared to the blood cardioplegia group. Additionally, the del Nido group achieved a reduction in surgery duration, as evidenced by the reduced aortic cross-clamping time (64.0 [55.5; 75.5] vs. 77.5 [65.0; 91.0] min, p = 0.001) and total operative time (287.5 [270.0; 305.0] vs. 315.0 [285.0; 365.0] min, p = 0.008). Subgroup analyses consistently demonstrated that the del Nido cardioplegia group had a significantly smaller postoperative increase in Troponin I levels across all subgroups (p < 0.05).Conclusionsdel Nido cardioplegia provided myocardial protection and favorable early postoperative outcomes compared to blood cardioplegia, making it a viable option for conventional coronary artery bypass grafting. Establishing a consensus on the protocol for Del Nido cardioplegia administration in adult surgeries is needed.

Robot-Assisted Minimally Invasive Coronary Artery Bypass Grafting: Total Arterial Revascularization Using the Double-Docking Technique.

The right internal mammary artery is considered to be the second choice for arterial conduits for coronary artery bypass grafting (CABG). However, the widespread use of bilateral internal mammary artery (BIMA) grafting is limited owing to increased technical demands, lengthy procedure, and high incidence of sternal wound complications. We compared the early clinical outcomes of a novel robot-assisted double-docking technique (DDT) with an open sternotomy technique for total arterial revascularization using BIMA. Between June 2019 and June 2023, 445 patients with multivessel coronary artery disease underwent open sternotomy CABG using BIMA grafting and 145 patients underwent robot-assisted BIMA grafting using DDT. Comparative analysis of 104 pairs of matched patients obtained using propensity score matching was performed. Procedural characteristics, postoperative 30-day mortality, and composite outcome (major adverse cardiac and cerebrovascular events) at a median follow-up of 1.5 years were evaluated. Preprocedural characteristics were well balanced between the groups after propensity matching. The number of distal anastomoses performed in the conventional group was statistically higher than that performed using DDT (P < 0.001). The durations of postsurgical ventilation, intensive care unit stay, and in-hospital stay were significantly lower with the DDT than with conventional CABG (P < 0.001). There was no significant difference in all-cause mortality or major adverse cardiac events between the DDT and conventional CABG groups at a median follow-up of 1.5 years. The DDT is feasible and efficacious for revascularization of multiple coronary targets in select individuals. It is equivalent to open sternotomy in terms of early clinical outcomes and superior to open sternotomy with regard to rates of sternal infection and intensive care unit and in-hospital stay.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review.

We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Sternum-sparing multivessel coronary surgery as a routine procedure: Midterm results of total coronary revascularization via left anterior thoracotomy

ObjectiveA sternum-sparing approach of minimally invasive total coronary revascularization via left anterior thoracotomy demonstrated promising early outcomes in unselected patients with coronary artery multivessel disease. Follow-up data are still missing. MethodsFrom November 2019 to September 2023, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed as a routine procedure in 392 consecutive, nonemergency patients (345 men; 67.0 ± 9.9 years; range, 32-88 years). All patients had multivessel coronary artery disease (77.6% 3-vessel-disease, 22.4% 2-vessel-disease, and 32.9% left main stenosis). Patients at old age (older than a 80 years, 12.5%), with severe left ventricular dysfunction (ejection fraction <30%, 7.9%), diabetes mellitus (34.9%), massive obesity (body mass index > 35, 8.9%), and chronic lung disease (17.1%) were included. Mean European System for Cardiac Operative Risk Evaluation II score was 2.9 ± 2.8. Mean midterm follow-up (100%) was 15.2 ± 10.7 months (range, 0.1-39.5 months). ResultsLeft internal thoracic artery (99.0%), radial artery (70.4%), and saphenous vein grafts (57.4%) were used, and 70.4% of patients received at least 2 arterial grafts. A total of 3.0 ± 0.8 anastomoses (range, 2-5 anastomoses) per patient were performed to revascularize the territories of left anterior descending (98.7%), circumflex (91.6%), and right coronary (70.9%) artery. Complete anatomical revascularization was achieved in 95.1%. At follow-up, all-cause-mortality, myocardial infarction, repeat revascularization, and stroke was 3.1%, 1.5%, 5.4%, and 0.7%, respectively. Overall major adverse cardiac and cerebrovascular events rate was 8.7%. ConclusionsThis is the first report of midterm follow-up after routine sternum-sparing total coronary revascularization via left anterior thoracotomy for multivessel coronary artery disease with a high rate of multiple arterial grafting and complete anatomical revascularization. Outcome was favorable and similar to that of contemporary conventional coronary artery bypass grafting.

Off-pump versus on-pump coronary artery bypass grafting in elderly patients at 30days: a propensity score matching study.

Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). A retrospective analysis was performed on patients aged 65years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P= .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.

Left ventricular recovery after total arterial coronary artery bypass grafting versus conventional coronary artery bypass grafting in patients with multivessel coronary artery disease and reduced left ventricular ejection fraction.

We compared total arterial revascularization (TAR) versus conventional revascularization (CR) in terms of left ventricular function recovery in patients with multivessel coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). We conducted a retrospective cohort study of 162 consecutive patients with multivessel CAD and reduced LVEF who underwent isolated coronary artery bypass grafting at our institution between January 2013 and July 2022. We assessed left ventricular function by transthoracic echocardiography at admission, before discharge, and at follow-up of 3, 6, and 12months, using LVEF, global longitudinal peak strain, end-diastolic volume index, and end-systolic volume index. We also evaluated mitral valve regurgitation and graft patency rate at 1 year. The TAR group had a significantly higher increase in LVEF and global longitudinal peak strain, and a significantly lower decrease in end-diastolic volume index and end-systolic volume index than the CR group at 6 and 12months after surgery. The TAR group also had a significantly lower degree of mitral valve regurgitation than the CR group at all-time points within 12months after surgery. The TAR group had a significantly higher graft patency rate than the CR group at 12months. There was no significant difference in hospital mortality or repeat revascularization between the groups. TAR was associated with better recovery of left ventricular function than CR in patients with multivessel CAD and reduced LVEF. Further studies are needed to confirm these findings in this high-risk population.

Early and long-term outcomes of less invasive approaches to coronary artery bypass surgery

This review outlines the development of less invasive treatments for coronary artery disease, focusing primarily on minimally invasive coronary artery bypass grafting (MICS CABG). We compare conventional coronary artery bypass grafting (CABG) and MICS CABG indications and contraindications, surgical techniques, early and long-term outcomes, and the process of implementation of MICS CABG to cardiac surgery programs. The invasiveness of cardiopulmonary bypass and the sternotomy incision used in conventional CABG are appreciably mitigated by the MICS CABG procedure, which is generally performed off-pump and through a left mini-thoracotomy. In the literature, MICS CABG is a feasible alternative to sternotomy CABG with safe, reproducible, efficient, and durable outcomes.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. We aimed to analyse clinical outcomes of robotic-assisted CABG. A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). Robotic-assisted CABG and HCR provides good long-term outcomes in patients who are not candidates for conventional CABG.

Early Post-operative Outcomes of Single versus Multiple Arterial Grafts in Coronary Artery Bypass Grafting; A Comparative Analysis

Objective: To compare early post-operative outcomes of Single versus Multiple Arterial grafts in Coronary Artery Bypass Grafting (CABG) surgery. Study Design: Analytical Cross-sectional study. Place and Duration of Study: Adult Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi Pakistan, from Jul 2022 to May 2023. Methodology: One hundred and forty nine patients planned for elective isolated CABG (with two or more grafts) were enrolled in study using consecutive sampling. They were allocated into two groups, group A (Multiple Arterial CABG group) and group B (Conventional CABG group). Data was collected on early post-op outcomes i.e. ICU stay, ventilation time, inotropic duration, chest drainage, rhythm complications including Supraventricular Tachycardia (SVT) and mortality using a structured proforma. Chi-square and t-test were applied to make comparison between both groups. p&lt;0.05 was considered statistically significant. Results: Out of one hundred and forty nine patients, who underwent elective CABG, majority were males 124(83.2%). Mean age of the patients was 59.18±9.28 years. Seventy four (49.7%) patients underwent Multiple Arterial CABG while 75(50.3%) had conventional CABG. Mean ICU stay duration was 56.74±48.30 hours in group A while it was 67.25±73.42 hours in group B; p=0.30. Mean Chest Drainage was 622.05±505.69 ml in group A while it was 846.13±799.67 ml in group B; p=0.04. Mean ventilation time was 10.28 ± 19.88 hours.................. Conclusion: The use of the Radial Artery (RA) in CABG surgery was associated with better early ...............

Short-Term Outcomes of Total Arterial Revascularization Compared to Conventional Coronary Artery Bypass Graft in Patients with Multivessel Disease and Left Ventricular Dysfunction

Background. Multivessel coronary artery disease (CAD) and left ventricular dysfunction (LVD) present challenges in CABG. We aimed to compare early outcomes of total arterial revascularization (TAR) versus conventional CABG in this high-risk population. Methods. This was a retrospective cohort study based on a single-center registry of patients who underwent isolated CABG for multivessel CAD and LVD between January 2014 and December 2022. Primary outcome was in-hospital mortality. Secondary outcomes were early complications, graft patency rate at 3 months, readmission rate within 6 months, and freedom from angina rate within 6 months. Results. A total of 112 cases were included in this study; 52 patients for TAR and 60 patients for conventional CABG. Both groups had comparable baselines and operative profiles. In-hospital mortality was similar between TAR and conventional CABG (2 deaths, 3.85% vs 4 deaths, 6.67%, p = 0.810). TAR had shorter ICU (3.5 vs 5 days, p = 0.016) and hospital stay (10.5 vs 12 days, p = 0.007). Other postoperative complications were similar. At 3 months, TAR had superior graft patency (91.7% vs 83.7%, p = 0.034) and lower 6-month readmission (TAR: 2/50, 4.0% vs. CR: 10/56, 17.9%, p = 0.024). Freedom from angina rate within 6 months was similar between the two groups (TAR: 43/50, 86.0% vs. CR: 42/56, 75.0%, p = 0.240). Conclusion. Our findings suggest that TAR may offer benefits in terms of shorter hospital stays, higher early graft patency, and lower readmission rates for patients with multivessel CAD and LVD. However, further research, particularly large-scale, randomized trials with longer follow-up periods, are needed to fully understand the long-term clinical outcomes and confirm these promising early results.

Surgical coronary angioplasty of both coronary ostia after chest radiotherapy. Is it good alternative to conventional coronary bypass surgery?

Isolated coronary ostial stenosis of both ostia is a rare, potentially life-threatening condition, occurring in 0.1%-0.2% of patients undergoing coronary angiography. We present a case of a 69-year-old woman with a past medical history of breast cancer, who had been treated with radiotherapy, which most likely caused significant stenosis of both coronary ostia and likely accelerated aortic stenosis. Surgical angioplasty with autopericardium patch reconstruction of the left main coronary artery and right coronary arteries due to proximal stenotic disease was performed instead of venous or arterial bypasses with concomitant aortic valve replacement. The postoperative course was uneventful. There were no cardiovascular events 5years after operation, and the patient remained free of any symptoms. Surgical coronary angioplasty offers an alternative to conventional coronary artery bypass grafting in isolated coronary ostial lesions and is advantageous in restoring more physiological myocardial perfusion, especially in those cases when conduits are suspected to be fibrotic, scarred or stenosed after radiation therapy or if there is the need to preserve conduits for future myocardial revascularisation in young patients.

Successful recognition and management of life-threatening multivessel coronary artery vasospasm after conventional coronary artery bypass grafting.

Background: The occurrence of native coronary artery vasospasm after coronary artery bypass grafting (CABG) is a rare phenomenon with potentially catastrophic outcomes. The absence of a clear understanding of contributing factors and an undetermined occurrence rate underscores the importance of coronary angiography as the primary diagnostic tool for this condition. Case Presentation: We present the case of a 70-year-old Asian male with a 14-year history of diabetes mellitus, seven years of Giant Cell Arteritis (GCA), and Ischemic Heart Disease (IHD). The patient experienced severe native coronary artery vasospasm following conventional CABG, prompting intervention through coronary angiography. Management &amp; Results: The patient underwent coronary angiography, revealing multivessel coronary artery vasospasm. Intracoronary administration of nitroglycerin and diltiazem was initiated promptly. The swift identification and treatment of vasospasm were instrumental in preventing severe myocardial injury. Conclusion: Coronary artery vasospasm post-CABG poses a significant threat, emphasizing the need for early identification and intervention. The successful management presented in this case underscores the importance of timely recognition and the administration of vasodilators in mitigating potential myocardial damage. This report contributes to the growing understanding of this rare but critical complication, highlighting the necessity for vigilance in post-CABG patient care.

Robotic-Assisted Versus Traditional Full-Sternotomy Coronary Artery Bypass Grafting Procedures: A Propensity-Matched Analysis of Hospital Costs

We aim to compare hospital costs of robotic-assisted coronary artery bypass grafting (CABG) versus conventional CABG. All consecutive 1,173 patients who underwent conventional and robotic-assisted CABG between January 2018 and June 2021 were included. After propensity-matching, 267 patients in each group (robotic-assisted vs conventional) were included in the study. Patient selection for each group was decided by a treating surgeon with a heart team based on clinical factors. Syntax score was not assessed. Total costs (direct+indirect hospital costs) of patients who underwent robotic-assisted and conventional CABG were compared. Direct cost expenses included surgical operating time, hospital stay, surgical implants and supplies, catheterization laboratory, pharmacy, radiology and ultrasound imaging, blood bank, cardiology, and so on. Indirect cost expenses included general administration medical records, and so on. Using the propensity-matched groups (n=267), we summed the total cost by year. Results for 267 propensity-matched patients (each group) evidenced that total conventional CABG costs were $9.5 million (average of $35,580/patient), whereas robotic-assisted CABG costs were $5 million ($18,726/patient). Therefore, the differences between robotic-assisted and conventional CABG costs were $4.5 million ($16,853/patient), favoring robotic-assisted over conventional CABG. Differences in direct and indirect costs were $2.2 million and $1.8 million, respectively. When the cost of the Da Vinci robot was added ($1,200,000), the total cost was $3.3 million ($12,359×patient) lower in the robotic-assisted CABG group. Multivariate analysis showed that, mainly, the shorter hospital length of stay (7 vs 5days) accounts for the reduced costs observed in the robotic-assisted CABG group. In conclusion, in a mature practice, robotic-assisted CABG decreases hospital length of stay, leading to reduced hospital costs compared with conventional CABG.

Long-Term Outcomes After Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting: Meta-Analysis of Kaplan–Meier-Derived Data

Hybrid coronary revascularization (HCR) is an alternative option to conventional coronary artery bypass grafting (CABG), but the long-term outcomes of HCR versus CABG remain unclear. We aimed to analyze the long-term outcomes after HCR and CABG for patients with multivessel coronary artery disease using meta-analysis. A systemic literature search of PubMed and EMBASE was performed from inception to March 2023. Studies reporting Kaplan-Meier curves with follow-up ≥1year were included. The primary outcome was all-cause mortality, and the secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and repeat revascularization. In total, 13 studies (1 randomized controlled trial and 12 propensity-score matched observational studies) were analyzed. The mean follow-up period was 5.1 ± 3.1years. HCR was associated with similar overall mortality (hazard ratio [HR] 1.09, 95% confidence interval [CI] 0.87 to 1.36), significantly higher incidence of MACCEs (HR 1.49, 95% CI 1.07 to 2.06), and repeat revascularization (HR 2.01, 95% CI 1.53 to 2.64) compared with CABG. In phase-specific analysis, the mortality rate was similar, and the incidence of repeat revascularization was higher in HCR regardless of phases. The incidence of MACCEs was higher in HCR during the mid-term phase (1 to 5years), but it was similar during the long-term phase (long-term: ≥5years). In conclusion, despite the higher incidence of MACCEs and repeat revascularization compared with CABG, HCR offered a similar long-term survival. Even longer-term follow-up and randomized controlled trials with a large population are warranted to investigate the role of HCR for multivessel coronary artery disease.