Coronary Artery Bypass Graft Surgery Research Articles

State Variation in Medicare Reimbursement for the Top 100 Cardiothoracic Surgery Procedures, 2013-2022.

Objective We analyzed changes in reimbursement rates for cardiothoracic surgery procedures from 2013 to 2022 to identify interstate variance andcompare changes in reimbursement between procedural groups. Methods The Center for Medicare and Medicaid Services database was analyzed to find the 100 highest-grossing cardiothoracic surgery CPT codes from 2013 to 2022. Medicare Administrative Contractor codes were utilized to identify reimbursement for each state. The payments were adjusted for inflation utilizing the consumer price index. Procedures were weighted according to revenue, and an average yearly, inflation-adjusted percent change in reimbursement was generated for each U.S. state. Procedural groups were compared using single-factor ANOVA and post-hoc tests. Results Since 2013, the inflation-adjusted Medicare reimbursement for the top cardiothoracic surgery procedures for all U.S. states and territories decreased by a yearly average of 2.67%. Puerto Rico (-0.33%), Louisiana (-1.84%), and Alabama (-1.85%) showed the smallest change. Illinois (-3.62%), Kansas (-3.40%), and Wyoming (-3.22%) had the greatest decrease in reimbursement throughout the observed period. Pacemaker and defibrillator (mean: -20.85), valvular (-22.07%), and coronary artery bypass graft(CABG) surgery (-21.99%) procedural groups demonstrated significant differences between valvular (p=0.01) or CABG (p=0.02) and pacemaker and defibrillator. Conclusions Our study confirms that reimbursement patterns vary by geographical area. Second, geographic variation suggests an incentive for physicians to practice in states with higher Medicare reimbursement. Certain procedural groups have been affected more than others. New lobbying strategies may be needed to mitigate diminishing reimbursement so that quality of care is not impacted for Medicare beneficiaries in low reimbursement states.

Efficacy of the Simulation-Based Education Approach Enhanced by Music on Anxiety, Physical Activity, and Respiratory Outcomes in Patients under Open Heart Surgery: A Randomized Three-Group Clinical Study.

Many patients with advanced cardiovascular disease need Coronary Artery Bypass Graft (CABG) surgery, indicating the importance of cardiac rehabilitation. Our study explored the combined efficacy of simulation (using demonstration and return-demonstration approach) with music on post-Open Heart Surgery (OHS) outcomes. This randomized, controlled trial was conducted at Imam Reza Hospital, Mashhad, Iran, on 90 patients awaiting OHS. The participants were allocated to 3 groups: education via simulation, education via simulation enhanced by instrumental music, and conventional instruction. Evaluations were performed pre-education and 2-days post-surgery using the activity measure for post-acute care (AM-PAC) "6-Clicks" Questionnaire, 18-item Nursing Outcomes Classification (NOC) index, and State-Trait Anxiety Inventory (STAI). JASP software (JASP Team, 2023, Version 0.17.3) was employed for statistical analyses, using RM-ANOVA and ANCOVA test. The results revealed a significant effect in immediate post-intervention and 2-day follow-up periods across all outcome measures (all p < 0.05), except for activity. Post hoc tests demonstrated substantial variations in effect sizes between intervention and control groups. Both intervention groups had significantly greater impact than the control group, particularly the composite group, showing heightened effects in state and trait anxiety and respiratory scores (p < 0.05). The combined use of the simulation with rhythmic music in phase one cardiac rehabilitation notably improved post-surgical outcomes, outperforming the method without music. This approach shows promise as an effective instructional strategy in cardiac rehabilitation stages.

Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery

Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly. To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger. This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023. Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment. The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm-related events, clinical outcomes, and cost related to the intervention. A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, -2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001). For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes. ClinicalTrials.gov Identifier: NCT04053816.

Cardiac Self-efficacy, Illness Perception and Health-Related Quality of Life in Patients with Ischemic Cardiomyopathy

Introduction: Illness perception and positive illness beliefs are protective factors that enhance the management of cardiac disease and improve HRQOL. The aim was to determine the relationship of cardiac self-efficacy and illness perception with HRQOL in patients with ischemic cardiopathy candidates for coronary artery bypass grafting surgery. Method: Cross-correlational study. 87 hospitalized patients with coronary artery disease requiring coronary revascularization surgery were recruited from a Cardiac Surgery Unit of a Hospital in Mexico City. Results: The study included 79.3% male patients with an average age of 63 years (S.D.=8.6). The correlation coefficient indicated a positive relationship between HRQOL and cardiac self efficacy (p=0.001), and a negative association between HRQOL and illness perception (p=0.001). Multiple regression analysis demonstrated a significant impact of illness perception and cardiac self-efficacy on the variability of HRQOL (p=0.046, β=0.200 and p=0.001, β=-0.412, respectively), regardless of the patient's age, gender, and education. Conclusion: Both cardiac self-efficacy and illness perception were found to be significantly linked to all aspects of health-related quality of life. These factors played a crucial role in explaining the variability of HRQOL regardless of the patient's age, gender, and education level. Patients who feel capable of managing the challenges posed by their illness tend to have a more positive perception of their HRQOL. Conversely, negative beliefs about heart disease were associated with a lower HRQOL.

The relationship between diastolic function characteristics and severe myocardial injury in coronary artery bypass graft surgery: a retrospective cohort study

The relationship between diastolic function characteristics and severe myocardial injury in coronary artery bypass graft surgery: a retrospective cohort study

Intraoperative Prediction of Coronary Graft Failure Based on Transit Time Flow Measurement: A PRELIMINARY STUDY.

Myocardial revascularization has been known to not affect the prognosis in some patients. Coronary artery bypass graft (CABG) failure may develop one year after CABG surgery. This is accompanied by a high risk of developing myocardial infarction after complete myocardial revascularization in obstructive coronary artery disease (CAD) due to microvascular dysfunction. The study of microvascular dysfunction using intraoperative stress tests with adenosine triphosphate (ATP) allows for the assessment of the coronary bypass flow reserve (CBFR) and the risk of graft failure one year after surgery. The study included 79 CAD patients (238 grafts) who underwent dynamic single-photon emission computed tomography (SPECT) before CABG and dynamic transit time flow measurement (TTFM) during CABG at rest and at stress. The CBFR was calculated by the ratio of the mean graft flow (MGF) at stress to the MGF at rest. A multivariate regression model showed that the MGF at rest (p = 0.043), the MGF at stress (p = 0.026) and the CBFR (p = 0.0001) were significant independent predictors of graft failure. As a result of ROC analysis, the threshold CBFR < 1.67 units correlated with graft failure more closely (sensitivity 82%, specificity 90%) The CBFR is a significant independent predictor of graft failure for up to 16 months.

Factors predicting depression among persons post-coronary artery bypass graft surgery: A cross-sectional study in Thailand.

Coronary artery bypass graft (CABG) surgery is a highly effective coronary artery disease treatment, providing immediate relief and promising long-term benefits. However, it is a major procedure with significant risks, including the potential for depression. Many patients experience depression following CABG, which can negatively impact their overall recovery, affecting both physical and mental health. This study aimed to determine factors predicting depression in patients following CABG surgery. This cross-sectional study was conducted with data collected between January and April 2024. A total of 272 post-CABG patients from two super tertiary care hospitals in Bangkok, Thailand, were recruited through purposive sampling. All research instruments were validated and tested for reliability. Data were analyzed using multiple regression analysis. The study found that hope, optimism, illness perception, social support, and anxiety were correlated with depression (adjusted R² = 0.381), but these variables explained only 38.1% of the variance (p <0.05). Among these factors, anxiety (β = 0.311), optimism (β = 0.203), social support (β = -0.117), and illness perception (β = -0.143) were significant predictors (p <0.05), while hope was not a significant predictor. Thus, anxiety emerged as the most crucial predictor of depression in patients who have undergone CABG. Nurses play a vital role in preventing and managing depression in post-CABG patients. Screening for anxiety and addressing it can prevent depression, enhance social support, and improve outcomes. To develop effective nursing strategies, it is essential for nurses to assess anxiety and implement interventions that promote social support, optimism, and illness perception. These measures can improve care quality, reduce readmission rates, and enhance patients' overall quality of life.

To be or not to be on: aspirin and coronary artery bypass graft surgery.

Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.

Caregiver burden in informal spousal caregivers predicts psychological and physical health in patients following coronary artery bypass graft surgery: a longitudinal clinical cohort study.

Previous research has shown that informal caregiver burden can have deleterious effects on patient recovery; however, this relationship has yet to be investigated in patients undergoing coronary artery bypass graft (CABG) surgery. This study aimed to examine the impact of the change of caregiver burden from pre- to post-surgery on patients' mental and physical health after CABG surgery. Ninety patient-caregiver dyads were assessed one month before the surgery, two months and one year after the surgery. Caregivers completed the Oberst Burden Scale to measure caregiver burden. Patients completed the Beck Depression Inventory to measure depressive symptoms, a subscale of the Hospital Anxiety and Depression Scale to measure anxiety symptoms, the Short Form-12 health assessment to measure health-related quality of life, and the Coronary Revascularisation Outcomes Questionnaire to measure surgery symptoms. Hierarchical linear regression analyses were conducted to explore the association between change in caregiver burden and post-surgery patient outcomes. A greater increase in caregiver burden from pre- to two-months post-surgery significantly predicted higher patients' depressive symptoms (β = 0.179, p = 0.010), anxiety symptoms (β = 0.114, p = 0.017), reported post-surgery symptoms (β = 0.335, p = 0.008) and reduced physical health-related quality of life (β = -0.358, p = 0.003), after controlling for a wide range of covariates. These findings were not replicated at a one-year follow-up. These results provide insights into the impact of caregiver burden on patient distress following CABG surgery, supporting the idea of psychological support interventions for caregivers to increase patients' short-term recovery outcomes.

Myocardial scar area predicts major adverse cardiovascular events after coronary artery bypass grafting in patients with ischemic cardiomyopathy

Objective: To investigate the value of myocardium scar area in predicting adverse cardiovascular events (MACEs) after coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy (ICM). Methods: The first part of this study was a retrospective study. Patients diagnosed with ICM and undergoing CABG surgery at Beijing Anzhen Hospital, Capital Medical University from January 2017 to December 2022 were enrolled as the discovery cohort. All patients underwent cardiac magnetic resonance-late gadolinium enhancement (CMR-LGE) before surgery. According to the occurrence of postoperative MACEs, the patients were divided into MACEs group and MACEs-free group. Preoperative clinical and imaging data, intraoperative and postoperative data were collected and compared between the two groups. The primary endpoint was postoperative MACEs. Univariate and multifactor regression analyses were used to analyze the risk factors for MACEs. Receiver operating characteristic (ROC) curves were constructed to evaluate the predictive efficacy and optimal cut-off value of myocardial scar area for endpoint events. The second part of this study was a prospective study. Patients with ICM who received CABG at Beijing Anzhen Hospital, Capital Medical University from January 2023 to June 2023 were enrolled as a validation cohort, and were divided into MACEs group and MACEs-free group according to whether MACEs occurred after surgery. Preoperative clinical and imaging data, intraoperative and postoperative data were collected and compared between the two groups. Verify the reliability of the cut-off value obtained by ROC curve in the validation cohort. Results: A total of 120 patients with ICM (30 patients in MACEs group and 90 patients in MACEs-free group), aged (61.6±8.7) years, including 93 males, were included in the discovery cohort. A total of 22 ICM patients (5 patients in MACEs group and 17 patients in MACEs-free group), aged (59.5±8.2) years, including 18 males, were included in the validation cohort. Multivariate Cox regression showed that myocardial scar area (HR=1.258, 95%CI 1.096-1.444, P=0.001) was an independent risk factor for the primary endpoint event. The area under ROC curve of myocardial scar area for predicting postoperative MACEs was 0.90 (95%CI 0.83-0.95), and myocardial scar area≥36.0% was the optimal cut-off value for predicting postoperative MACEs, and its sensitivity, specificity and accuracy were 96.7%, 72.2% and 78.3%, respectively. In the validation cohort, the sensitivity, specificity and accuracy of myocardial scar area in predicting postoperative MACEs in patients with ICM after CABG were 80.0%, 82.4% and 81.8%, respectively. Conclusion: Myocardial scar area is an independent risk factor for MACEs after CABG in patients with ICM, and myocardial scar area≥36.0% is the optimal cut-off value for predicting MACEs after CABG. Myocardial scar area can help to identify patients at high risk of surgery and provide a basis for risk stratification of patients.

Sex, Atrial Fibrillation, and Long-Term Mortality After Cardiac Surgery

There are limited data on the association of sex with the incidence of postoperative atrial fibrillation (poAF) and subsequent long-term mortality after cardiac surgery. To evaluate whether the incidence of poAF and associated long-term mortality after cardiac surgery differ by sex. This retrospective cohort study was conducted at 2 tertiary care centers in Massachusetts from January 1, 2002, until October 1, 2016, with follow-up until December 1, 2022. Adult (aged >20 years) women and men undergoing coronary artery bypass graft surgery, aortic valve surgery, mitral valve surgery, and combined procedures with cardiopulmonary bypass were examined using medical records. Patients who had data on poAF were included in data analyses. Sex and poAF. Primary outcomes were the incidence of poAF and all-cause mortality. poAF was defined as any atrial fibrillation detected on electrocardiogram (EKG) during the index hospitalization in patients presenting for surgery in normal sinus rhythm. Data on poAF were obtained from EKG reports and supplemented by information from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. All-cause mortality was assessed via hospital records. The hypotheses were formulated prior to data analysis. Among 21 568 patients with poAF data (mean [SD] age, 66.5 [12.4] years), 2694 of 6601 women (40.8%) and 5805 of 14 967 men (38.8%) developed poAF. In a multivariable logistic regression model, women had lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P < .001). During the follow-up study period, 1294 women (50.4%) and 2376 men (48.9%) in the poAF group as well as 1273 women (49.6%) and 2484 men (51.1%) in the non-poAF group died. Cox proportional hazards analysis found that the association between poAF and mortality was significantly moderated (ie, effect modified) by sex. Compared with same-sex individuals without poAF, men with poAF had a 17% higher mortality hazard (hazard ratio [HR], 1.17; 95% CI, 1.11-1.25; P < .001), and women with poAF had a 31% higher mortality hazard (HR, 1.31; 95% CI, 1.21-1.42; P < .001). In this retrospective cohort study of 21 568 patients who underwent cardiac surgery, women were less likely to develop poAF than men when controlling for other relevant characteristics; however, women who did develop poAF had a higher risk of long-term mortality than men who developed poAF. This observed elevated risk calls for a tailored approach to perioperative care in women undergoing cardiac surgery.

Role of Intraoperative Left Ventricular Global Longitudinal Strain in Hemodynamic and Cognitive Outcomes in On-Pump Coronary Artery Bypass Surgery: A Prospective Observational Study

ABSTRACT Background: The role of left ventricular global longitudinal strain (LVGLS) in coronary artery bypass grafting (CABG) and outcomes such as low cardiac output syndrome (LCOS) is not well established. The authors investigated the relationship between LVGLS before and after induction of anesthesia, their differences, and their relationship with LCOS and other outcomes. Methodology: A prospective observational study was conducted in a public/private hospital with 50 adult patients scheduled for on-pump CABG with normal left ventricular ejection fraction (LVEF). Acoustic windows necessary to obtain the 2D-LVGLS were acquired with transthoracic echocardiography (TTE) before induction of anesthesia (LVGLSBI) and after with mechanical ventilation (LVGLSAI) using transesophageal echocardiography (TEE). LCOS was defined as the use of epinephrine, dobutamine, and/or milrinone at minimum IV doses of 1 μg/min-1, 2.5 μg/kg-1/min-1, and 0.375 μg/kg-1/min-1, respectively, for a minimum of 24 h after cardiopulmonary bypass. Results: A dedicated workstation (EchoPAC Software v203, GE) was used for offline calculation of LVGLS. LVGLSBI did not have a significant correlation with LCOS (mean difference, 1.66; 95% CI, −–3.63 to 3.05; P = 0.862), nevertheless, it was an independent risk factor of in-hospital mortality (OR, 0.74; 95% CI, 0.57–0.95; P = 0.02), 3-month mortality (OR, 0.80; 95% CI, 0.64–0.99; P = 0.05), and delirium (OR, 0.65; 95% CI, 0.43–0.97; P = 0.03) in the multivariate analysis. LVGLSAI was also an independent risk factor for 3-month mortality (OR, 0.78; 95% CI, 0.62–0.99; P = 0.04). Conclusions: In CABG surgeries, LVGLS was a predictor of adverse outcomes in both awake and anesthetized patients with normal LVEF.

Influence of Diabetes Mellitus on Changes in Intra-Operative Decision Making in Coronary Artery Bypass Grafting

Background: We evaluated whether patients with diabetes mellitus experienced more surgical strategy changes than patients without diabetes when undergoing coronary artery bypass graft surgery utilizing a protocol for intraoperative high frequency ultrasound and transit-time flow measurement. Methods: Outcomes of coronary artery bypass grafting (CABG) patients with and without diabetes enrolled in the multicenter prospective Registry for Quality Assessment with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery (REQUEST) study were retrospectively compared. The primary endpoint was frequency of intraoperative surgical strategy changes. We also evaluated the differences in patient characteristics and operative characteristics including graft configuration. Results: We compared 614 non-diabetic patients with 402 diabetic patients, among whom 128 were insulin dependent. Patients with diabetes had higher rates of surgical strategy change for the aortic component of the operation (10.2% vs. 6.4%, odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.06–2.65; p = 0.026). Surgical strategy changes related to in-situ conduits were more common in on-pump procedures in comparison to off-pump in diabetics (4.0% vs. 0%; p = 0.007). Diabetes was associated with less frequent use of bilateral internal mammary arteries (BIMA) (25.6% vs. 33.7%; p = 0.006), more frequent use of radial artery (31.3% vs. 16.9%; p &lt; 0.001) and multi-arterial configuration (48.3% vs. 39.9%, p = 0.009), and more total grafts (3.1 ± 1.1 vs. 2.8 ± 0.9; p &lt; 0.001). Conclusions: When performing isolated CABG on diabetic patients, surgeons were more likely to change surgical strategy for the aortic component of the operation based on high-frequency ultrasound (HFUS), and more likely to make a change related to in-situ conduits in on-pump procedures in diabetics. Among diabetic patients, there was less frequent use of BIMA, more frequent use of radial artery, more frequent multi-arterial configuration, and more total grafts.

Predicting New-Onset Atrial Fibrillation in Patients with Coronary Artery Bypass Graft: the Precise-Dapt Score

&lt;b&gt;Aim:&lt;/b&gt;&amp;nbsp;Postoperative new-onset atrial fibrillation (POAF) after isolated coronary artery bypass graft surgery (CABG) is associated with adverse events. The Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score is used to predict the bleeding risk after dual antiplatelet therapy and has been associated with arrhythmias in recent years. Therefore, the present study sought to investigate the association between the PRECISE-DAPT score and POAF after coronary artery bypass graft surgery.&lt;br /&gt; &lt;b&gt;Materials and Methods:&lt;/b&gt;&amp;nbsp;350 patients who underwent CABG were retrospectively screened. After exclusion criteria, 135 patients were included in the study. A total of 135 patients who underwent on-pump CABG were divided into two groups: patients with POAF and those without POAF. The PRECISE-DAPT score was calculated for each patient, and intergroup comparisons of the calculated scores were performed.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt;&amp;nbsp;POAF was detected in 66 patients out of 135. Patients with POAF had longer hospital stays. PRECISE-DAPT score was higher in the patients with POAF compared to the patients without POAF (p&amp;lt;0.001). PRECISE-DAPT score was determined to be a predictor of POAF after CABG (odds ratio [OR]: 1.305; 95% confidence interval [CI]: 1.268–2.030; p&amp;lt;0.001).&amp;nbsp;The PRECISE-DAPT score for POAF risk had a sensitivity of 60% and a specificity of 79% at cut-off values of 14.5 and above.&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt;&amp;nbsp;An increased PRECISE-DAPT score may be used as a predictive score for POAF that may develop during hospital stay after on-pump CABG.

The Association of Cerebral Autoregulation Dysfunction and Postoperative Memory Impairment in Cardiac Surgery Patients.

Background and Objectives: Cardiac surgery is associated with various durations of cerebral autoregulation (CA) impairment and can significantly impact cognitive function. Cognitive functions such as memory, psychomotor speed, and attention are significantly impacted after cardiac surgery, necessitating prioritization of these areas in cognitive function tests. There is a lack of research connecting cerebral autoregulation impairment to specific cognitive function domains after cardiac surgery. This study aimed to determine if impaired cerebral autoregulation is associated with postoperative memory impairment and to test the hypothesis that the duration of this impairment affects the development of postoperative memory issues. Materials and Methods: A prospective study was conducted in 2021-2023. After approval of the Ethics Committee and with patient's written consent, 83 adult patients undergoing elective on-pump coronary artery bypass graft (CABG) surgery were enrolled. All patients were assessed for cognitive function 1 day before surgery using the Mini-Mental state examination (MMSE-2) test as a screening tool and the Hopkins Verbal Learning Test-Revised (HVLT-R) to assess memory specifically. To diagnose possible memory impairment (IM), all patients underwent a repeat assessment of cognitive function on the 7th-10th postoperative day. Cerebral autoregulation monitoring using transcranial Doppler was performed. Cerebral autoregulation status index (Mx) was recorded using Intensive Care Brain Monitoring System software, 9.1.5.23 (Cambridge, UK). Results: According to our research, the incidence of postoperative memory impairment is 30.1%. Temporary cerebral autoregulation impairment occurs in all patients undergoing elective in-pump CABG surgery. The duration of the single longest CA impairment event in seconds (LCAI) and the LCAI dose were higher in patients with postoperative memory impairment, p = 0.006 and p < 0.007, respectively. Conclusions: Cerebral autoregulation impairment is important in developing memory loss after cardiac surgery. The duration and dose of the LCAI event are predictive of postoperative memory impairment.

Effect of Ticagrelor Versus Clopidogrel After Off-Pump Coronary Artery Bypass Grafting on Postoperative Atrial Fibrillation: A Cohort Study.

This study aimed to explore the effect of a P2Y12 inhibitor regimen on the occurrence of postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass graft surgery in carriers with the cytochrome P450 family 2 subfamily C member19 loss-of-function allele. From May 2019 to November 2023, patients containing the cytochrome P450 family 2 subfamily C member19*2 or *3 allele undergoing elective first-time off-pump coronary artery bypass graft surgery including aspirin 100 mg/d and ticagrelor 180 mg/d (AT group; n=95) versus clopidogrel 75 mg/d (aspirin and clopidogrel group; n=95) were prospectively followed. The primary end point was the cumulative incidence of POAF in a week. The secondary end points were POAF burden, platelet aggregability, systemic immune-inflammation index and heart rate variability. The incidence of POAF was 21.1% in the AT group versus 41.1% in the aspirin and clopidogrel group (hazard ratio, 0.46 [95% CI, 0.27-0.76]; P=0.003). POAF burden, ADP-induced platelet aggregation and systemic immune-inflammation index was notably lower in the AT group than the aspirin and clopidogrel group. Heart rate variability data showed an increase in both high-frequency and SD of normal-to-normal RR intervals in the AT group with a decreased low-frequency/high-frequency ratio, suggesting that the sympathetic/parasympathetic activation was balanced. In patients carrying the cytochrome P450 family 2 subfamily C member19 loss-of-function allele, an AT regimen after off-pump coronary artery bypass grafting was associated with a lower incidence of POAF, paralleled by lower atrial fibrillation burden, ADP-induced platelet aggregation, lower systemic immune-inflammation index reaction, and a balanced automatic nerve system compared with an aspirin and clopidogrel regimen. Inhibiting the systemic immune-inflammation response and sustaining automatic nerve balance may underlie the therapeutic effect of POAF by a potent antiplatelet combination.

Is it feasible to treat atrial fibrillation at the time of minimally invasive coronary artery bypass grafting?

Coronary artery bypass grafting remains the most common operation performed by cardiac surgeons. As a result, a cardiac surgeon with a typical practice will most commonly encounter atrial fibrillation when performing coronary artery bypass grafting. In this review, we first emphasize the importance of treating atrial fibrillation in patients undergoing coronary bypass grafting. We review benefits of concomitant surgical ablation and its importance relative to complete coronary revascularization. We then discuss options to treat atrial fibrillation in a more minimally invasive manner in these patients, while still preserving treatment efficacy. Surgical ablation at the time of coronary artery bypass grafting surgery could be as important as complete revascularization. Bi-atrial ablation provides superior rhythm control compared to left-sided ablation only. We highlight various options for surgical ablation at the time of coronary artery bypass grafting surgery, and provide an algorithm for ablation in individual patients.

Perioperative anaesthetic management of an elderly high-risk male with cardiac ochronosis undergoing aortic valve replacement with coronary artery bypass graft: A case report.

Alkaptonuria is a rare autosomal recessive congenital disorder of metabolism that affects 1 in 250,000 live births. It manifests as ochronosis and degenerative arthritis due to the accumulation of homogentistic acid in cartilage and heart valves along with precipitation of renal, salivary, pancreatic and gall bladder calculi. It is noted to cause cardiac valve stenosis and regurgitation secondary to calcification leading to cardiac failure in 10% of patients. Through this report, we present a successful perioperative anaesthetic management of a 74-year-old man with cardiac ochronosis, who underwent an aortic valve replacement with coronary artery bypass graft surgery at our centre.

Peripheral artery disease in chronic total occlusion percutaneous coronary intervention.

The impact of peripheral artery disease (PAD) on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. We analyzed the association of PAD with CTO-PCI outcomes using data from the PROGRESS-CTO registry of procedures performed at 47 centers between 2012 and 2023. The prevalence of PAD among 12 961 patients who underwent CTO PCI during the study period was 13.9% (1802). PAD patients were older, more likely to be current smokers, and had higher rates of dyslipidemia, diabetes, cerebrovascular disease, hypertension, prior myocardial infarction, PCI, and coronary artery bypass graft surgery. Their PROGRESS-CTO (1.35 vs 1.22; P < .001) and J-CTO (2.63 vs 2.33; P < .001) scores were higher, lesion length was longer, and angiographic characteristics were more complex. Their access site was more likely to be bifemoral (33.6% vs 30.9%; P = .024) compared with patients with no PAD. Technical (82.9% vs 87.7%; P < .001) and procedural (80.5% vs 86.6%; P < .001) success rates were lower in patients with PAD, while the incidence of major adverse cardiovascular events (MACE) was higher (3.1% vs 1.8%; P < .001), with higher mortality (0.8% vs 0.4%; P = .034), acute myocardial infarction rate (0.9% vs 0.4%; P = .010), and perforations rate (6.6% vs 4.5%; P < .001). In multivariable analysis, PAD was associated with higher MACE (odds ratio [OR]: 1.53; 95% CI, 1.01-2.26; P = .038) and lower technical success (OR: 0.82; 95% CI, 0.69-0.99; P = .039). PAD patients undergoing CTO PCI have higher comorbidity burden, more complex CTOs, higher MACE, and lower technical success.

Successful Extracorporeal Cardiopulmonary Resuscitation Despite Aortic Occlusion.

We present the case of a 62-year-old man with severe coronary artery disease who presented to the hospital in refractory ventricular fibrillation cardiac arrest. He showed signs of life despite prolonged resuscitation. We thus decided to initiate extracorporeal cardiopulmonary resuscitation (ECPR). The patient had a known total occlusion of his infrarenal aorta that had been surgically bypassed with a bifemoral-axillary graft. We successfully initiated ECPR via the surgical graft, establishing blood flow to the central circulation through the axillary artery in a peripheral configuration while ensuring blood flow to the left leg via the femoral-femoral graft. The patient was extubated neurologically intact the following day and subsequently underwent coronary artery bypass graft surgery while on extracorporeal membrane oxygenation (ECMO) support. He was subsequently weaned off inotropic support and decannulated from ECMO. He was discharged home neurologically intact and independent in his activities of daily living. This case demonstrates that cannulation for ECPR via a surgical vascular graft is possible and that a total occlusion of the infrarenal aorta in the presence of a surgical bypass is not an absolute contraindication to ECMO.