Coronary Artery Bypass Grafting Cohort Research Articles

Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study.

Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms. This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition. Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1month post-CABG. Women in this CABG cohort were more likely to have depression at baseline and 1month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)—356 patients or percutaneous coronary intervention (PCI)—679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Air Pollution and Adverse Cardiovascular Events After Coronary Artery Bypass Grafting: A 10-Year Nationwide Study

BackgroundIncreased particulate matter <2.5 μm (PM2.5) air pollution is associated with adverse cardiovascular outcomes. However, its impact on patients with prior coronary artery bypass grafting (CABG) is unknown. ObjectivesThe purpose of this study was to evaluate the association between major adverse cardiovascular events (MACE) (defined as myocardial infarction, stroke, or cardiovascular death) and air pollution after CABG. MethodsWe linked 26,403 U.S. veterans who underwent CABG (2010-2019) nationally with average annual ambient PM2.5 estimates using residential address. Over a 5-year median follow-up period, we identified MACE and fit a multivariable Cox proportional hazard model to determine the risk of MACE as per PM2.5 exposure. We also estimated the absolute potential reduction in PM2.5 attributable MACE simulating a hypothetical PM2.5 lowered to the revised World Health Organization standard of 5 μg/m3. ResultsThe observed median PM2.5 exposure was 7.9 μg/m3 (IQR: 7.0-8.9 μg/m3; 95% of patients were exposed to PM2.5 above 5 μg/m3). Increased PM2.5 exposure was associated with a higher 10-year MACE rate (first tertile 38% vs third tertile 45%; P < 0.001). Adjusting for demographic, racial, and clinical characteristics, a 10 μg/m3 increase in PM2.5 resulted in 27% relative risk for MACE (HR: 1.27, 95% CI: 1.10-1.46; P < 0.001). Currently, 10% of total MACE is attributable to PM2.5 exposure. Reducing maximum PM2.5 to 5 μg/m3 could result in a 7% absolute reduction in 10-year MACE rates. ConclusionsIn this large nationwide CABG cohort, ambient PM2.5 air pollution was strongly associated with adverse 10-year cardiovascular outcomes. Reducing levels to World Health Organization-recommended standards would result in a substantial risk reduction at the population level.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease: An Updated Systematic Review and Meta-Analysis.

Recently, both US and European guidelines have predominantly recommended coronary artery bypass grafting (CABG) as the preferred revascularisation method. However, emerging data have raised the possibility of percutaneous coronary intervention (PCI) being a viable and effective alternative. This meta-analysis sought to evaluate the latest insights from major clinical trials to ascertain whether PCI could be as effective as CABG in treating left main coronary artery (LMCA) disease. To achieve this, a comprehensive systematic search was conducted across databases, including Medline (via PubMed), Embase, Cochrane, and clinicaltrials.gov. The search spanned from the inception of these databases to August 20, 2022, and exclusively focused on randomized controlled trials (RCTs). Employing the random effects model, selected studies underwent rigorous analysis. The study outcomes encompassed a spectrum of factors such as all-cause mortality, major adverse cerebrovascular and cardiovascular events (MACCE), myocardial infarction (MI), stroke, and revascularisation procedures. The observation periods of interest included the 30-day mark, 1 year, 5 years, and 10 years. The analysis integrated six RCTs, revealing noteworthy patterns. In terms of all-cause mortality, PCI demonstrated non-inferiority to CABG across all observed time frames: 30 days (OR 0.6), 1 year (OR 0.77), 5 years (OR 1.41), and 10 years (OR 1.08). Analysis of MACCE outcomes favored PCI at 30 days and CABG at 5 years. The utilisation of the original five-year EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularisation) trial definition for MI highlighted higher MI rates for PCI compared to CABG (OR 1.66, P < 0.05). Intriguingly, when the subsequently released EXCEL data, aligned with the third universal MI definition, was incorporated, the five-year data consistently leaned towards CABG. Specifically, the PCI group exhibited 7.5% MI rates in contrast to the 3.6% in the CABG cohort (OR 2.19, P < 0.001). Concerning stroke, PCI proved advantageous at 30 days and 1 yearwhile exhibiting no significant disparity at 5 and 10 years. Revascularisation procedures favoured CABG at one and five years, with comparability at the remaining time points. In summation, the outcomes of this comprehensive meta-analysis suggest that PCI could serve as a feasible alternative to CABG in the context of uncomplicated LMCA disease. It's worth noting that CABG might still hold an advantage for complex lesions.

Validating the SMART2 Score in a Racially Diverse High-Risk Nationwide Cohort of Patients Receiving Coronary Artery Bypass Grafting.

Background We tested the potential of the Secondary Manifestations of Arterial Disease (SMART2) risk score for use in patients undergoing coronary artery bypass grafting. Methods and Results We conducted an external validation of the SMART2 score in a racially diverse high-risk national cohort (2010-2019) that underwent isolated coronary artery bypass grafting. We calculated the preoperative SMART2 score and modeled the 5-year major adverse cardiovascular event (cardiovascular mortality+myocardial infarction+stroke) incidence. We evaluated SMART2 score discrimination at 5 years using c-statistic and calibration with observed/expected ratio and calibration plots. We analyzed the potential clinical benefit using decision curves. We repeated these analyses in clinical subgroups, diabetes, chronic kidney disease, and polyvascular disease, and separately in White and Black patients. In 27 443 (mean age, 65 years; 10% Black individuals) US veterans undergoing coronary artery bypass grafting (2010-2019) nationwide, the 5-year major adverse cardiovascular event rate was 25%; 27% patients were in high predicted risk (>30% 5-year major adverse cardiovascular events). SMART2 score discrimination (c-statistic: 64) was comparable to the original study (c-statistic: 67) and was best in patients with chronic kidney disease (c-statistic: 66). However, it underpredicted major adverse cardiovascular event rates in the whole cohort (observed/expected ratio, 1.45) as well as in all studied subgroups. The SMART2 score performed better in White than Black patients. On decision curve analysis, the SMART2 score provides a net benefit over a wide range of risk thresholds. Conclusions The SMART2 model performs well in a racially diverse coronary artery bypass grafting cohort, with better predictive capabilities at the upper range of baseline risk, and can therefore be used to guide secondary preventive pharmacotherapy.

Systemic and local vascular inflammation and arterial reactive oxygen species generation in patients with advanced cardiovascular diseases.

Systemic inflammation may cause endothelial activation, mediate local inflammation, and accelerate progression of atherosclerosis. We examined whether the levels of circulating inflammatory cytokines reflect local vascular inflammation and oxidative stress in two types of human arteries. Human internal mammary artery (IMA) was obtained in 69 patients undergoing coronary artery bypass graft (CABG) surgery and left anterior descending (LAD) artery was obtained in 17 patients undergoing heart transplantation (HTx). Plasma levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6) and interleukin-1β (IL-1β) were measured using ELISA, high-sensitivity C-reactive protein (hs-CRP) was measured using Luminex, and mRNA expression of proinflammatory cytokines in the vascular tissues was assessed. Furthermore, formation of superoxide anion was measured in segments of IMA using 5 uM lucigenin-dependent chemiluminescence. Vascular reactivity was measured using tissue organ bath system. TNF-α, IL-6 and IL-1β mRNAs were expressed in all studied IMA and LAD segments. Plasma levels of inflammatory cytokines did not correlate with vascular cytokine mRNA expression neither in IMA nor in LAD. Plasma TNF-α and IL-6 correlated with hs-CRP level in CABG group. Hs-CRP also correlated with TNF-α in HTx group. Neither vascular TNF-α, IL-6 and IL-1β mRNA expression, nor systemic levels of either TNF-α, IL-6 and IL-1β were correlated with superoxide generation in IMAs. Interestingly, circulating IL-1β negatively correlated with maximal relaxation of the internal mammary artery (r = -0.37, p = 0.004). At the same time the mRNA expression of studied inflammatory cytokines were positively associated with each other in both IMA and LAD. The positive correlations were observed between circulating levels of IL-6 and TNF-α in CABG cohort and IL-6 and IL-1β in HTx cohort. This study shows that peripheral inflammatory cytokine measurements may not reflect local vascular inflammation or oxidative stress in patients with advanced cardiovascular disease (CVD). Circulating pro-inflammatory cytokines generally correlated positively with each other, similarly their mRNA correlated in the arterial wall, however, these levels were not correlated between the studied compartments.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018

Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score–matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10–2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19–4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.

Coronary atherosclerotic burden assessed by SYNTAX scores and outcomes in surgical, percutaneous or medical strategies: a retrospective cohort study

IntroductionCoronary atherosclerotic burden and SYNTAX Score (SS) are predictors of cardiovascular events.ObjectivesTo investigate the value of SYNTAX scores (SS, SYNTAX Score II (SSII) and residual SYNTAX Score (rSS)) for predicting...

Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention

BackgroundData comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients. MethodsThis retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed. ResultsThe total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01). ConclusionsPatients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.

Post-Coronary Artery Bypass Grafting Cognitive Decline: Risk Modification And Implications For Screening In Low-Risk Population

Background — Postoperative cognitive dysfunction (POCD) is an important complication of coronary artery bypass grafting (CABG). Large amount of data points to the problem of POCD in patients with high surgical risk of CABG. Low-risk patients are not safe from these complications either. Assessment of the severity, duration of POCD, degree of recovery and risk factors in off- and on-pump patients with stable coronary artery disease is crucial in minimization of the POCD risk in patients with low surgical risk. Objective — to analyze incidence, severity, reversibility and risk factors of POCD in patients undergoing elective low-risk CABG. Methods and Results — The retrospective cohort study included 79 patients who underwent on-pump (N=44) or off-pump (N=35) elective CABG with low surgical risk (mean EuroSCORE II death risk 1.08±0.71%), with observation period of 6 months. Pre-CABG markers of cognitive impairment were found in 50% of patients, with 44% of patients demonstrating POCD. Patients who underwent off-pump CABG demonstrated more pronounced decline in MoCA score compared to on-pump (-3.9±2.0 vs. -2.2±2.0 at 8 days point, p=0.018), with regress to pre-CABG results after 3 weeks. Baseline MoCA score &lt;25 was found to be a predictor for more pronounced cognitive decline at 8 days point. MMSE demonstrated less predictive value compared to MoCA. Conclusion — POCD risk differs in off-pump and on-pump CABG cohorts, with significantly higher prevalence in the former group, whether assessed using MMSE or MoCA tests. Differences are observed within 3 weeks post-CABG. Pre-CABG MoCA score &lt;25 is associated with more pronounced POCD in low-risk elective CABG cohort.

Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional Study

It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery. A retrospective, observational study. Two university-affiliated tertiary care centers. A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). None. A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk. Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.

Abstract 9296: Impact of the Covid Pandemic on Aortic Valve Replacement and Coronary Artery Bypass Graft Surgical Outcomes

Introduction: Patients with coronary artery disease or cardiac valvular disease in need of cardiac surgery are typically high-risk, and may have been impacted either by delays in seeking care for their underlying cardiac condition, or by disruptions in hospital care itself. Hypothesis: we examined changes in volume, complexity, and outcomes for aortic valve replacement (AVR) and coronary artery bypass graft (CABG) patients at a large midwestern teaching hospital during the COVID pandemic. Methods: We used diagnosis and procedure codes to identify all patients undergoing AVR or CABG, without a documented COVID19 diagnosis, at Barnes-Jewish Hospital between 1/2018 and 9/2020. We used multivariable regression models to examine the association between the COVID time period and outcomes, controlling for age, sex, and medical comorbidities. Results: For the AVR and CABG cohort, we saw no statistically significant differences in weekly volume, age, gender, payor, or race (Table 1).In the AVR cohort, patients were more complex during COVID, and risk-adjusted in-hospital mortality was higher during COVID compared to pre-COVID. For the CABG cohort, we found numeric increases but no statistically significant differences in patient complexity, nor in risk-adjusted mortality (Figure 1). Conclusions: We found higher in-hospital mortality among patients undergoing AVR during COVID, a pattern that was not statistically significant in CABG. These findings suggest that outreach to patients is critical to ascertain which patients require necessary surgical care during future pandemic waves or other disruptions to usual care.

Daytime and outcomes after cardiac surgery: Systematic review and metaanalysis, insights from a large UK database review and post-hoc trial analysis.

BackgroundSeveral studies have suggested a variation of myocardial tolerance to ischaemia depending on the daytime of surgery. To test this hypothesis, we conducted a three-level analysis: metaanalysis, national patient-level dataset analysis and a post-hoc trial analysis.MethodsWe first performed a systematic review and metaanalysis of available studies comparing clinical outcomes following cardiac surgery performed in the morning (am) versus afternoon (pm). Then, we interrogated the UK national adult cardiac surgery audit database (NACSA) and analysed the am or pm outcomes of patients undergoing non-emergency aortic valve replacement (AVR) or coronary artery bypass grafting (CABG). In a post-hoc analysis, we further investigated the effect of time of surgery on serum troponin release and ventricular myocardial biopsy adenine nucleotide metabolism.ResultsA total of 18377 patients undergoing uncomplicated isolated CABG or isolated AVR on the same day am or pm were included in the metaanalysis. Meta-analytic estimates showed no difference in the risk of MI between patients operated in pm vs am (OR 1.02, 95% CI:0.79–1.32) and in the risk of mortality (OR 1.1, 95% CI:0.85-1.42). Outcomes of 91248 patients from the NACSA dataset were analysed according to the daytime of the procedure. Patient-level analysis showed no significant effect of daytime for both isolated AVR (p=0.094) and isolated CABG (p=0.425). Finally, we performed a post-hoc trial database analysis in 124 patients undergoing isolated AVR or CABG of serial cardiac troponin and nucleotides metabolism on ventricular myocardial biopsies. We found no significant diurnal changes in the perioperative cardiac troponin release or nucleotide metabolism in the AVR (p=0.30) or the CABG cohort (p=0.97).ConclusionThe present three-level analysis found no evidence that daytime influences clinical outcomes and myocardial injury in patients undergoing cardiac surgery.

Multiple arterial conduits for multi-vessel coronary artery bypass grafting in patients with mild to moderate left ventricular systolic dysfunction: a multicenter retrospective study

BackgroundAdvantages of multiple arterial conduits for coronary artery bypass grafting (CABG) have been reported previously. We aimed to evaluate the mid-term outcomes of multiple arterial CABG (MABG) among patients with mild to moderate left ventricular systolic dysfunction (LVSD).MethodsThis multicenter study using propensity score matching took place from January 2013 to June 2019 in Jiangsu Province and Shanghai, China, with a mean and maximum follow-up of 3.3 and 6.8 years, respectively. We included patients with mild to moderate LVSD, undergoing primary, isolated multi-vessel CABG with left internal thoracic artery. The in-hospital and mid-term outcomes of MABG versus conventional left internal thoracic artery supplemented by saphenous vein grafts (single arterial CABG) were compared. The primary end points were death from all causes and death from cardiovascular causes. The secondary end points were stroke, myocardial infarction, repeat revascularization, and a composite of all mentioned outcomes, including death from all causes (major adverse events). Sternal wound infection was included with 6 months of follow-up after surgery.Results243 and 676 patients were formed in MABG and single arterial CABG cohorts after matching in a 1:3 ratio. In-hospital death was not significantly different (MABG 1.6% versus single arterial CABG 2.2%, p = 0.78). After a mean (±SD) follow-up time of 3.3 ± 1.8 years, MABG was associated with lower rates of major adverse events (HR, 0.64; 95% CI, 0.44–0.94; p = 0.019), myocardial infarction (HR, 0.39; 95% CI, 0.16–0.99; p = 0.045) and repeat revascularization (HR, 0.42; 95% CI, 0.18–0.97; p = 0.034). There was no difference in the rates of death, stroke, and sternal wound infection.ConclusionsMABG was associated with reduced mid-term rates of major adverse events and cardiovascular events and may be the procedure of choice for patients with mild to moderate LVSD requiring CABG.

Daytime and Outcomes After Cardiac Surgery: Systematic Review and Meta-Analysis, Insights From a Large UK Database Review and Post-Hoc Trial Analysis

Background: Several studies have suggested a variation of myocardial tolerance to ischaemia depending on the daytime of surgery. To test this hypothesis, we conducted a three-level analysis: meta-analysis, national patient-level dataset analysis and a post-hoc trial analysis. Methods: We first performed a systematic review and meta-analysis of available studies comparing clinical outcomes following cardiac surgery performed in the morning (am) versus afternoon (pm). Then, we interrogated the UK national adult cardiac surgery audit database (NACSA) and analysed the am or pm outcomes of patients undergoing non-emergency aortic valve replacement (AVR) or coronary artery bypass grafting (CABG). In a post-hoc analysis, we further investigated the effect of time of surgery on serum troponin release and ventricular myocardial biopsy adenine nucleotide metabolism. Results: A total of 18377 patients undergoing uncomplicated isolated CABG or isolated AVR on the same day am or pm were included in the meta-analysis. Meta-analytic estimates showed no difference in the risk of MI between patients operated in pm vs am (OR 1.02, 95% CI:0.79–1.32) and in the risk of mortality (OR 1.1, 95% CI:0.85-1.42). Outcomes of 91248 patients from the NACSA dataset were analysed according to the daytime of the procedure. Patient-level analysis showed no significant effect of daytime for both isolated AVR (p=0.094) and isolated CABG (p=0.425). Finally, we performed a post-hoc trial database analysis in 124 patients undergoing isolated AVR or CABG of serial cardiac troponin and nucleotides metabolism on ventricular myocardial biopsies. We found no significant diurnal changes in the perioperative cardiac troponin release or nucleotide metabolism in the AVR (p=0.30) or the CABG cohort (p=0.97). Conclusion: The present three-level analysis found no evidence that daytime influences clinical outcomes and myocardial injury in patients undergoing cardiac surgery. Funding: This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust, and the University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Declaration of Interest: None to declare.

Risk stratification in unprotected left main coronary disease: do we have the tools?

Abstract Introduction The evolution of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) techniques made the choice of the optimal revascularization strategy of unprotected left main coronary disease (ULMD) challenging. Scoring systems are useful tools for the decision-making process and for risk stratification. Purpose To evaluate 1) the performance of the SYNTAX score I (SSI) and II (SSII) and Euroscore II (EII) in risk stratification and 2) the outcome predictors of patients (pts) with ULMD, according to the treatment strategy chosen (PCI or CABG). Methods Retrospective single centre cohort study of 440 consecutive pts (age 68±11 years; 76.6% male) with significant ULMD (defined as left main coronary artery stenosis &amp;gt;50%, with no patent arterial or venous bypass graft to left anterior descending artery), who were submitted to PCI (n=135) or CABG (n=307), between January 2006 and December 2018. Median follow-up (FU) was 4.0±1.8 years. The primary outcome was a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and target lesion revascularization (TLR). Results During the FU period, there were 112 (25.5%) CV deaths, 26 (5,9%) non-fatal MI and 53 (12.0%) TLR. Multivariate analysis of pts submitted to PCI showed that SSII and anatomical complete revascularization were independent predictors of the primary outcome (HR 1.045, CI 1.015–1.075, p=0.003 and HR 3,014, CI 1.655–5.489, p&amp;lt;0.0001, respectively). The 63 pts submitted to PCI, who had a SSII favoring CABG, had slightly more adverse events (42.9% vs 41.7%, p=0.889). In the CABG cohort, only SSII was an independent predictor of the outcome by multivariate analysis (HR 1.061, CI 1.035–1.086, p&amp;lt;0.0001). The ROC curve analysis for all cohort presented no discriminative capacity for SSI (AUC 0.538, CI 0.482–0.593, p=0.186) and a weak discrimination for SSII (AUC 0.659, CI 0.605–0.713, p&amp;lt;0.0001) and EII (AUC 0.653, CI 0.599–0.707, p&amp;lt;0.0001; Figure 1). The difference between SSII and EII was not statistically significant (DeLong test p=0.828). Similar results were found when analysing the CAGB group, however, in PCI cohort, SII and EII showed an acceptable discriminative capacity (AUC 0.722, CI 0.636–0.809, p&amp;lt;0.0001 and AUC 0.700, CI 0.610–0.791, p&amp;lt;0.0001, respectively). Conclusion In a real-world ULMD population, the most common risk scores, mainly those integrating anatomical and clinical features, presented a very modest role in the risk stratification, both in chronic and acute coronary syndromes. However, in pts with ULMD submitted to PCI, those risk scores had a more significant role in the risk stratification of these pts. Figure 1. SSI, SSII, EII ROC curves for all cohort Funding Acknowledgement Type of funding source: None

Unraveling the impact of time-dependent perioperative variables on 30-day readmission after coronary artery bypass surgery

ObjectivesReadmission within 30 days of discharge after coronary artery bypass grafting is a measure of quality and a driver of cost in health care. Traditional predictive models use time-independent variables. We developed a new model to predict time to readmission after coronary artery bypass grafting using both time-independent and time-dependent preoperative and perioperative data. MethodsAdults surviving to discharge after isolated coronary artery bypass grafting at a multi-hospital academic health system from January 2017 to September 2018 were included in this study. Two distinct data sources were used: the institutional cardiac surgical database and the clinical data warehouse, which provided more granular data points for each patient. Patients were divided into training and validation sets in an 80:20 ratio. We evaluated 82 potential risk factors using Cox survival regression and machine learning techniques. The area under the receiver operating characteristic curve was used to estimate model predictive accuracy. ResultsWe trained the model with 21 variables that scored a P value of less than .05 in the univariable analysis. The multivariable model determined 16 significant risk factors, and 6 of them were time-dependent. These included preoperative hemoglobin a1c level, preoperative creatinine, preoperative hematocrit, intraoperative hemoglobin, postoperative creatinine, and postoperative hemoglobin. Area under the receiver operating characteristic values were 0.906 and 0.868 for training and validation sets, respectively. ConclusionsTime-dependent perioperative variables in an isolated coronary artery bypass grafting cohort provided better predictive ability to a readmission model. This study was unique in the inclusion of time-dependent covariates in the predictive model for readmission after discharge after coronary artery bypass grafting.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with reduced ejection fraction

ObjectiveThe aim of this study was to evaluate comparative outcomes for percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with reduced ejection fraction. MethodsAll patients from the University of Pittsburgh Medical Center from 2011 to 2018 who had reduced preoperative ejection fraction (<50%) and underwent CABG or PCI for coronary revascularization were included in this study. Patients were risk-adjusted with propensity matching (1:1) and primary outcomes included long-term survival, readmission, and major adverse cardiac and cerebrovascular events (MACCE). ResultsA total of 2000 patients were included in the current study, consisting of CABG (n = 1553) and PCI (n = 447) cohorts with a mean ejection fraction of 35% ± 9.53%. Propensity matching yielded a 1:1 match with 324 patients in each cohort, controlling for all baseline characteristics. Thirty-day mortality was similar for PCI versus CABG (6.2% vs 4.9%; P = .49). Overall mortality over the study follow-up period (median, 3.23 years; range, 1.83-4.98 years) was significantly higher for the PCI cohort (37.4% vs 21.3%; P < .001). Total hospital readmissions (24.1% vs 12.9%; P = .001), cardiac readmissions (20.4% vs 11.1%; P = .001), myocardial infarction event (7.7% vs 1.8%; P = .001), MACCE (41.4% vs 23.8%; P < .001), and repeat revascularization (6.5% vs 2.6%; P = .02) occurred more frequently in the PCI cohort. Freedom from MACCE at 1 year (74.4% vs 87.0%; P < .001) and 5 years (54.5% vs 74.0%; P < .001) was significantly lower for the PCI cohort. On multivariable cox regression analysis, CABG (hazard ratio, 0.57; 95% confidence interval, 0.44-0.73; P < .001) was significantly associated with improved survival. Prior liver disease, dialysis, diabetes, and peripheral artery disease were the most significant predictors of mortality. The cumulative incidence of hospital readmission was lower for the CABG cohort (hazard ratio, 0.51; 95% confidence interval, 0.37-0.71; P < .001). Multivariable cox regression for MACCE (hazard ratio, 0.48; 95% confidence interval, 0.39-0.58; P < .001) showed significantly fewer events for the CABG cohort. ConclusionsPatients with reduced ejection fraction who underwent CABG had significantly improved survival, lower MACCE, and fewer repeat revascularization procedures compared with patients who underwent PCI.

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

As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.