Coronary Artery Bypass Grafting Group Research Articles

Heart surgery over two decades: what we have learned about results and changing risks

ObjectivesUsing the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients.MethodsThis serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS).ResultsA total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001.ConclusionsIsolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings.Graphical

The Influence of Myocardial Revascularization on the Condition of the Distal Part of Coronary Arteries in Patients with Type 2 Diabetes Mellitus

The aim. To study the dynamics of the internal lumen of the distal part of coronary arteries after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with type 2 diabetes mellitus
 Materials and methods. This retrospective study included 121 patients with coronary artery disease and type 2 diabetes mellitus after revascularization of coronary arteries through PCI or CABG. In order to evaluate the changes in the condition of the distal sections of the coronary arteries after stenting and CABG, we included patients with type 2 diabetes mellitus in whom repeated coronary angiography was performed 12-60 months after PCI or CABG. The quantitative method (quantitative coronary angiography) and semi-quantitative assessment scales were used to assess the dynamics of the distal part of the coronary arteries.
 Results. The mean age of the patients was 56.2 ± 0.4 years for patients who underwent CABG and 54.3 ± 0.4 years for patients who underwent PCI. There were 64.7% men in the CABG group and 54.0% in the PCI group. The use of drug-eluting stents didn’t affect the internal lumen of the distal part of the arteries. After implantation of bare metal stents, progression of diffuse atherosclerotic lesions was detected. The use of arterial grafts during CABG improved the condition of the inner lumen of the bypassed vessel. However, after venous grafts placement, the patency of the distal coronary arteries may deteriorate in the future.
 Conclusions. In people with type 2 diabetes mellitus and coronary artery disease, after cardiac surgery, the smaller branches of the blood vessels can become narrower over the next 1-5 years if a stent without medication or a vein graft is used. However, when a drug-eluting stent or an artery graft is used, the smaller vessel branches stay about the same or even improve over time.

Effect of on-Pump and Off-Pump Coronary Artery Bypass Graft on Length of Icu Stay among Low Ejection Fraction Patients Going through Cardiac Revascularization

Background Coronary artery bypass grafting (CABG) remains a cornerstone in the management of coronary artery disease, especially for patients with severe left ventricular dysfunction. The debate between on-pump and off-pump CABG techniques centers on their impact on postoperative outcomes, particularly the length of ICU stay, which has significant implications for patient recovery and healthcare resources. Objective This study aimed to compare the effects of on-pump and off-pump coronary artery bypass grafting on the length of ICU stay among patients with severe left ventricular dysfunction undergoing cardiac revascularization, with a view to optimizing postoperative outcomes and resource utilization in this high-risk patient population. Methods A longitudinal cross-sectional study was conducted, enrolling 78 participants scheduled for CABG at a single center over one year. Participants were divided into two groups: those undergoing on-pump CABG (n=44) and those undergoing off-pump CABG (n=34). Data collection focused on demographic information, clinical characteristics, and the length of ICU stay. Statistical analysis employed SPSS v25, utilizing means, standard deviations, and Independent t-tests to compare outcomes between the two groups. Results The study revealed that patients undergoing on-pump CABG had a significantly shorter mean ICU stay (4 ± 3.9 days) compared to the off-pump CABG group (5 ± 4.4 days), with a P value of 0.01. Further stratification showed that older patients and those with comorbidities such as diabetes and hypertension experienced longer ICU stays, irrespective of the surgical technique used. Conclusion On-pump CABG is associated with shorter ICU stays compared to off-pump CABG in patients with severe left ventricular dysfunction, suggesting that the on-pump technique may be preferable for optimizing postoperative recovery and resource allocation in this patient cohort.

Endarterectomy may be an effective additional treatment for three diffuse coronary artery disease complicated with diabetes.

In order to evaluate the clinical efficacy of coronary endarterectomy (CE) and coronary artery bypass grafting (CABG) in patients with diabetes complicated with three diffuse coronary artery stenosis. A retrospective analysis was conducted on 460 patients with diabetes mellitus and diffuse three-vessel coronary artery disease who underwent CABG in our department from September 2015 to December 2021. The patients were divided into two groups according to whether they underwent CE: the simple CABG group (group A, n = 254) and the CABG combined CE group (group B, n = 206). The perioperative outcomes, recurrent angina pectoris during 1-year follow-up, and the patency rate of the grafted vessel in coronary CT angiography were compared between the two groups. There was no significant difference in the 30days mortality rate between the two groups (2.3% vs 2.4%, p < 0.05). Group A had a shorter operation time [(3.55 ± 0.59) h versus (4.35 ± 0.65) h], less bypass grafts [(2.72 ± 0.83) versus (3.65 ± 0.72) vessels/case], a lower incidence of perioperative myocardial infarction (7.1% vs 12.6%), and a lower number of patent graft vessels at 1-year follow-up [(2.15 ± 0.42) versus (2.88 ± 0.68) vessels/case] compared with group B (all p < 0.05). Group A had a higher incidence of recurrent angina during follow-up (14.49% vs 6.47%) (p < 0.05). Although there was no significant difference in the incidence of MACCE events between the two groups, the probability of revascularization was higher in group A. Compared with single CABG, combined CE in patients with diabetes mellitus and diffuse three-vessel coronary artery disease can achieve more complete revascularization, reduce the recurrence of angina pectoris and the needing of postoperative revascularization, but the incidence of perioperative myocardial infarction is higher.

Single-Photon Emission Computed Tomography in the Diagnosis of Early Postoperative Cognitive Dysfunction After Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting

Objective: to study the contribution of regional cerebral blood flow (rCBF) indicators to the diagnosis of early postoperative cognitive dysfunction (POCD) in patients with multifocal atherosclerosis (MFA) with heart and brain revascularization.Material and methods. The study involved 45 patients with MFA of coronary and precerebral arteries. We analyzed patients’ cognitive indicators and conducted brain scintigraphy before and after revascularization. The criteria for inclusion in the study were: scheduled combined revascularization of coronary and precerebral arteries; signed informed consent to participate in the study. Criteria for exclusion were: refusal to participate in the study, diseases that would prevent examination. The study of cognitive functions was performed using flow was assessed by single-photon emission computed tomography using lipophilic radiopharmaceutical 99mTc-HMPAO “Ceretec”.Results. The frequency of early POCD in the isolated coronary artery bypass grafting (CABG) group was 73.3%, in the combined carotid endarterectomy (СEA) and CABG group it was 72.5% (p ˃ 0.05). The rCBF index in the isolated CABG group compared with the combined СEA and CABG group was higher in the right and left temporal lobes (p = 0.01 and p = 0.04), in the right frontal lobe (p = 0.03), right parietal lobe (p = 0.005), and in the right and left occipital lobes (p = 0.03 and p = 0.03). In the postoperative period, in the isolated CABG group, right parietal lobe perfusion (p = 0.01), and right and left occipital lobe perfusion (p = 0.01 and p = 0.01) decreased compared to the baseline values. In the combined СEA and CABG group, in the early postoperative period, cerebral perfusion did not change significantly. Right parietal lobe perfusion was higher in the isolated CABG group compared with the combined CABG and СEA group (p = 0.04). The greatest contribution to the development of early POCD in patients after isolated CABG was made by the left temporal lobe perfusion (p = 0.025), in patients after combined CABG and СEA – by the right parietal lobe perfusion (p = 0.04) in the early postoperative period.Conclusion. Assessment of cerebral perfusion in patients before and after surgery can be used to identify areas affected during surgery, as a method for monitoring the safety of procedure, and as an assessment of the preventive methods against POCD.

Early-Staged Carotid Artery Stenting Prior to Coronary Artery Bypass Grafting: Analysis of the Early and Mid-Term Results in Comparison with a Consecutive Cohort of Isolated Coronary Artery Surgery Patients.

The aim of the present study was to analyze retrospectively the results of patients who underwent early-staged, i.e., within 24-48 h, carotid artery stenting (e-s CAS) before coronary artery bypass grafting (CABG). Between December 2014 and December 2022, 1046 consecutive patients underwent CABG; 31 of these patients (3%) were subjected to e-s CAS prior to CABG (e-s CAS + CABG group). Preoperative and intraoperative variables and early and mid-term results of the e-s CAS + CABG group were compared with those of patients who underwent isolated CABG (CABG group). As compared with the CABG group, the e-s CAS + CABG group showed a worse clinical risk profile due to higher Euroscore-2 values and incidence of obstructive pulmonary disease and bilateral carotid artery and peripheral artery diseases (p < 0.05, for all comparisons). The combined end point of operative mortality, periprocedural myocardial infarction, and stroke was 3.2% (0%/0%/3.2%) in the e-s CAS + CABG group vs. 5.9% (2.2%/2.8%/0.9%) in the CABG group (p > 0.5, for all measurements). At 5 years, actuarial survival was 74% ± 16% in the e-s CAS + CABG group vs. 93% ± 4.0% in the CABG group, freedom from cardiac death was 100% vs. 98% ± 1.0% (p = 0.6), and freedom from MACCEs was 85% ± 15% vs. 97% ± 2.5% (p > 0.1, for all comparisons). Independent predictors of all-causes death were advanced age at the operation (p < 0.0001), a lower value for left ventricular ejection fraction (p = 0.05), and a high Euroscore-2 (p = 0.04). CABG preceded by e-s CAS appears to be associated with satisfactory early outcomes while limiting the risk of myocardial infarction to a very short time interval between the two procedures. Freedom from late all-causes death, cardiac death, and MACCEs were comparable and equally satisfactory, underscoring the positive protective effects of CAS and CABG on the carotid and coronary territories over time.

Impacts of the SYNTAX score I, II and SYNTAX score II 2020 on left main revascularization

Patients with left main coronary artery disease (LMCAD) with a high SYNTAX score (SS) were excluded from randomized studies that comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). We sought to compare PCI and CABG in the real-world practice and investigate the impact of SS I, SS II, and SS II 2020 on clinical outcomes. In total, 292 Patients with LMCAD (173 PCI, 119 CABG) treated between 2017 and 2021 were enrolled. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, stroke, or myocardial infarction (MI). The mean SS I was high in both groups (PCI vs. CABG: 31.64 ± 11.45 vs. 32.62 ± 11.75, p = 0.660). The primary outcome occurred in 28 patients (16.2%) in the PCI group and in 19 patients (16.0%) in the CABG group without significant difference [adjusted hazard ratio, 95% CI = 0.98 (0.51–1.90), p = 0.97] over the follow-up period (26.9 ± 17.7 months). No significant difference was observed in all-cause mortality (11.6% vs. 11.8%, p = 0.93) or stroke rates (3.5% vs. 5.0%, p = 0.51) between groups. However, PCI was associated with higher MI (4.6% vs. 0.8%, p < 0.05) and revascularization rates (26% vs. 5.9%, p < 0.001). Prognostic value of the SS I, SS II and SS II 2020 on the primary outcome was not relevant in the PCI group. Among patients with LMCAD, PCI and CABG did not significantly differ in the composite endpoint of all-cause death, stroke, and MI. These results support the potential expansion of PCI indications in LMCAD management for whom are ineligible for CABG with complex coronary artery disease.

Response shift in coronary artery disease.

Patients with coronary artery disease (CAD) experience significant angina symptoms and lifestyle changes. Revascularization procedures can result in better patient-reported outcomes (PROs) than optimal medical therapy (OMT) alone. This study evaluates the impact of response shift (RS) on changes in PROs of patients with CAD across treatment strategies. Data were from patients with CAD in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease (APPROACH) registry who completed the 16-item Canadian version of the Seattle Angina Questionnaire at 2weeks and 1year following a coronary angiogram. Multi-group confirmatory factor analysis (MG-CFA) was used to assess measurement invariance across treatment groups at week 2. Longitudinal MG-CFA was used to test for RS according to receipt of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy (OMT) alone. Of the 3116 patients included in the analysis, 443 (14.2%) received CABG, 2049(65.8%) PCI, and the remainder OMT alone. The MG-CFA revealed a partial-strong invariance across the treatment groups at 2weeks (CFI = 0.98, RMSEA [90% CI] = 0.05 [0.03, 0.06]). Recalibration RS was detected on the Angina Symptoms and Burden subscale and its magnitude in the OMT, PCI, and CABG groups were 0.32, 0.28, and 0.53, respectively. After adjusting for RS effects, the estimated target changes were largest in the CABG group and negligible in the OMT group. Adjusting for RS is recommended in studies that use SAQ-CAN to assess changes in patients with CAD who have received revascularization versus OMT alone.

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 ...............

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

To the Editor: Acute kidney injury (AKI) is a frequent complication of both cardiac and major non-cardiac surgeries. Cardiopulmonary bypass (CPB)-assisted cardiac surgery was associated with a higher incidence of AKI than other surgeries without CPB, suggesting that CPB might be a risk factor for cardiac surgery-associated AKI (CSA-AKI).[1] However, previous studies have demonstrated conflicting results regarding the association of CPB and CSA-AKI, as the diagnosis of AKI has been made according to different criteria.[2-5] The most recent definition of AKI from an AKI Work Group, Kidney Disease: Improving Global Outcomes (KDIGO), allows for the determination of AKI based on a decline in the glomerular filtration rate (GFR) with subsequent increase in serum creatinine or a period of oliguria.[6] We performed a retrospective cohort study to evaluate the association of CPB and postoperative AKI, using the KDIGO definition among patients undergoing on-pump or off-pump coronary artery bypass graft (CABG). From September 29, 2016, to October 07, 2017, patients aged ≥18 years who underwent elective, isolated CABG at Xijing Hospital were included. The exclusion criteria included a history of previous cardiac surgery, hemodynamic instability, estimated GFR of <30 mL·min−1·1.73 m−2 at baseline, or unavailability of a baseline renal function test. Hemodynamic instability here constitutes preoperative cardiogenic shock and use of preoperative intra-aortic balloon pump (IABP), ventricular assist devices, or preoperative cardiopulmonary resuscitation. Our study adheres to the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology. We collected baseline demographic information and data on clinical comorbidities and preoperative medications from all patients from the cardiothoracic surgery database at Xijing Hospital. Data on intraoperative anesthesia management were obtained from anesthesia and medical records of Xijing Hospital. Age, sex, GFR, ejection fraction (EF), European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), and history of diabetes, hypertension, myocardial infarction (MI), stroke, peripheral arterial disease, and chronic obstructive pulmonary disease were determined from the electronic health records. Preoperative use of the following medications was also recorded: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), diuretics, calcium channel blockers, nitrates, and β-blockers, and whether β-blockers were administered in the morning of the day of the surgery. Serum creatinine level and EF at baseline were defined as the latest measurements before surgery. GFR was estimated using the Cockcroft-Gault equation: GFR=[(140 − age) × (weight in kg) × (0.85 if female)]/(72 × serum creatinine). The following intraoperative variables were collected: duration of the operation, number of grafts, adverse events, sufentanyl dosage, and use of IABPs. The primary outcome was the incidence of postoperative AKI. We adopted the definition of AKI by the KDIGO, as a rise in serum creatinine by 0.3 mg/dL in 48 h or a rise in serum creatinine 1.5 times the baseline over 7 postoperative days.[7] As urine output was unavailable after patients were discharged from the intensive care unit (ICU), it was not used to diagnose AKI in this study. Secondary outcomes were in-hospital medical expenses, length of stay, mortality, and composite outcomes including all-cause mortality, MI, stroke, repeat revascularization, or acute renal failure requiring renal replacement therapy. Composite outcomes were determined 1 year after surgery via a follow-up phone call. Definitions of secondary outcomes and telephone follow-ups are described in the Supplementary Materials, https://links.lww.com/CM9/B348. This study was approved by the Institutional Ethics Review Committee of Xijing Hospital (approval No. KY20192156-C-1). It was exempt from the requirement of informed consent due to ethical considerations, and we obtained the oral consent of patients via telephone follow-up. The patients volunteered to tell their long-term outcomes, to which no patient objected. All tests and confidence intervals (CIs) were two-sided, and statistical significance was set at P < 0.05. All analyses were conducted using R (http://www.R-project.org, c) and Free Statistics software version 1.4 (Beijing FreeClinical Medical Technology Co., LTD, China). Please refer to the supplementary material, https://links.lww.com/CM9/B348 for a detailed statistical analysis. Between September 29, 2016, and October 7, 2017, 242 patients underwent isolated CABG. Eight patients were excluded from the study: two had a history of cardiac surgery, one had an estimated GFR of <30 mL·min−1·1.73 m−2 at baseline, two died prior to the postoperative renal function test, two had duplicated electronic medical records, and one was missing serum creatinine data. In total, 234 patients (195 [83.3%] men and 39 [16.7%] women) were included in the final study analysis; 107 (46%) underwent on-pump CABG and 127 (54%) underwent off-pump CABG [Supplementary Figure 1, https://links.lww.com/CM9/B348]. The mean age of the patients was 61.3 ± 7.6 years. The mean preoperative GFR was 67.0 ± 15.8 mL·min−1·1.73 m−2, the median of EuroSCORE II was 1.2 (interquartile range [IQR]: 0.9–1.7), and the mean preoperative EF was 54.4 ± 7.1. Supplementary Table 1, https://links.lww.com/CM9/B348 shows the main demographic characteristics and incidence of preoperative comorbidities grouped by patients who underwent on-pump or off-pump procedures. Compared with patients who underwent on-pump CABG, more patients in the off-pump group were provided with nitrates and β-blockers preoperatively (66.9% vs. 48.6%, P = 0.007 for nitrates; 92.1% vs. 68.2%, P < 0.001 for β-blockers). Patients in the off-pump group tended to have less vessels grafted, shorter operative duration (142.4 ± 38.0 min vs. 268.1 ± 55.5 min, P < 0.001), less intraoperative sufentanyl administered (250.0 [IQR: 225.0–300.0] μg vs. 450 [IQR: 387.5–500.0] μg, P < 0.001), and higher standardized sufentanyl dose (by operative time and expressed as microgram per minute) (1.8 [IQR: 1.4–2.1] μg/min vs. 1.7 [IQR: 1.4–2.0] μg/min, P = 0.046). During the first 7 postoperative days, 117 AKI events occurred in the entire cohort, including 105 stage I AKIs, 7 stage II AKIs, and 5 stage III AKIs; and one patient required renal replacement therapy. The incidence of postoperative AKI was 69.1% in the on-pump CABG cohort and 33.9% in the off-pump CABG cohort (absolute risk difference, 35.2% [95% CI, 23.3–47.3%]) [Supplementary Table 2, https://links.lww.com/CM9/B348]. The association between CPB exposure and postoperative AKI is shown in Table 1. In the unadjusted model, exposure to CPB was associated with an increased risk of postoperative AKI (risk ratio, 2.04 [95% CI, 1.40–2.97], P<0.001). In the adjusted models, after the potential confounders were adjusted and controlled, the direction of association was unchanged. A potential confounder was statistically significant in the univariate analysis of factors affecting AKI [Supplementary Table 3, https://links.lww.com/CM9/B348]. In the fully adjusted model, in which we adjusted for age, sex, GFR, preoperative use of β-blockers, number of grafts, EuroSCORE II, standardized sufentanyl dose, preoperative use of digoxin, and history of stroke, CPB was an independent risk factor for AKI (relative risk [RR], 1.73, [95% CI, 1.14–2.63], P = 0.01) during the first 7 postoperative days. The association with postoperative AKI was statistically significant in all strata of the population investigated according to age, sex, history of stroke, history of diabetes, history of hypertension, history of MI, preoperative use of ACEI or ARB, and preoperative GFR [Supplementary Figure 2, https://links.lww.com/CM9/B348]. The E-values of the RR for the point estimate and lower confidence bound for the incidence of AKI were 2.85 and 1.54, respectively. Table 1 - Association between CPB and incidence of AKI using poisson regression models. Poisson regresssion models Crude Model 1 Model 2 Model 3 Model 4 Groups RR (95% CI) P value RR (95% CI) P value RR (95% CI) P value RR (95% CI) P value RR (95% CI) P value Off-pump 1.00 NA 1.00 NA 1.00 NA 1.00 NA 1.00 NA On-pump 2.04 (1.40, 2.97) <0.001 1.79 (1.18, 2.71) 0.006 1.77 (1.17, 2.68) 0.007 1.75 (1.15, 2.65) 0.008 1.73 (1.14, 2.63) 0.010 Model 1: adjusted for age, sex, GFR, preoperative use of β-blockers, and number of grafts. Model 2: adjusted for age, sex, GFR, preoperative use of β-blockers, number of grafts, and EuroSCORE II. Model 3: adjusted for age, sex, GFR, preoperative use of β-blockers, number of grafts, EuroSCORE II, and standardized sufentanyl dose. Model 4: adjusted for age, sex, GFR, preoperative use of β-blockers, number of grafts, EuroSCORE II, standardized sufentanyl dose, preoperative use of digoxin, and history of stroke. AKI: Acute kidney injury; CI: Confidence interval; CPB: Cardiopulmonary bypass; EuroSCORE II: European System for Cardiac Operative Risk Evaluation II; GFR: Glomerular filtration rate; NA: Not available; RR: Relative risk. The on-pump CABG group was associated with a significant increase in total costs, postoperative costs, length of ICU stay, and postoperative in-hospital stay compared with the off-pump CABG group [Supplementary Table 2, https://links.lww.com/CM9/B348]. AKI was associated with increased costs and length of hospital stay after adjusting for potential confounders [Supplementary Table 4, https://links.lww.com/CM9/B348]. The CORONARY trial reported a reduction in ICU stay as a secondary outcome in patients undergoing off-pump CABG,[3] which is consistent with our findings. Mediation analysis demonstrated that the increased incidence of AKI mediated a 18.17% increment in postoperative costs, as well as a 17.10% increase in total costs and a 25.69% increase in the length of postoperative in-hospital stay after on-pump CABG [Supplementary Figure 3, https://links.lww.com/CM9/B348]. Follow-up at 1 year was completed in 215 patients (91.5%). All-cause mortality was 5.2% and 4.1% in the off-pump and on-pump groups, respectively (P = 0.73). There was no statistically significant difference in the rate of 1-year composite outcomes between the off-pump and on-pump groups (24.1% vs. 28.6%; P = 0.47) [Supplementary Figures 4, https://links.lww.com/CM9/B348 and 5, https://links.lww.com/CM9/B348]. However, the 1-year all-cause mortality (P = 0.06) and composite outcomes (P = 0.0072) were significantly higher in patients who developed postoperative AKI than in those who did not, regardless of whether the surgery was performed with or without CPB assistance [Supplementary Figures 6, https://links.lww.com/CM9/B348 and 7, https://links.lww.com/CM9/B348]. This single-center observational study was limited by the inherent limitations due to its retrospective nature. We did not collect data on preoperative contrast. However, there was no difference in baseline GFR levels, which may rule out the possibility of contrast-induced kidney damage. In addition, the E-values indicated that the observed RR of 1.73 for incident AKI could only be explained by unmeasured confounders, such as contrast exposure, by a risk ratio of >2.85, and beyond that of the confounders that were measured in this study (lower confidence bound, 1.54). According to the KDIGO definition, the risk of AKI after CABG was significantly higher in the on-pump group than in the off-pump group, with a 73% RR increase for AKI in patients exposed to CPB after adjustment for confounding factors. Meanwhile, our subgroup analysis revealed a consistent and robust association between CPB and the risk of AKI across strata. Additional studies are warranted to replicate and confirm these findings using different surgical procedures and in different populations. If an association or causality is established, this may justify a shift toward less invasive surgical procedures. Furthermore, if CPB is deemed necessary, intensive and comprehensive renal protective strategies should be considered when caring for such patients. Funding This work is supported by a grant from the Natural Science Foundation of China (No. 81970448). Conflicts of interest None.

Meta-analysis of clinical adverse events after CABG vs. PCI in patients with chronic kidney disease and coronary artery disease

AimTo investigate the efficacy and postoperative clinical adverse events of coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for chronic kidney disease (CKD) study participants combined with coronary artery disease (CAD).MethodsAll randomized controlled trials (RCTs) that focus on the therapeutic effect evaluation of CABG and PCI and their effect on postoperative clinical adverse events as well as main adverse cardiovascular and cerebrovascular events (MACCEs) in CKD study participants with CAD were screened from the following databases, including CNKI, CBM, Wan Fang, VIP, Embase, PubMed, as well as Cochrane library clinical controlled trials. The study was conducted under the PRISMA 2020 criteria. Data were extracted, and quality control was evaluated from the modified Jadad rating scale. Meta-analysis was then undertaken through STATA 16.0 software.ResultsA total of 5 RCTs were obtained, including 1198 patients. Study participants were subdivided into two groups, including the PCI group (n = 604) and the CABG group (n = 594). Meta-analysis of clinical adverse events results showed that the long-term survival results of CAD patients with CKD who underwent PCI were worsened compared to CABG, such as long-term MACCEs (RR = 1.59, 95%CI: 1.04–2.43) and the long-term repeated revascularization (RR = 2.48, 95%CI: 1.76–3.49). Also, cardiac death (RR = 1.68, 95%CI:1.04–2.71), as well as cerebrovascular accident (RR = 1.74, 95%CI:1.04–2.90) in CABG group was significantly lower than that in PCI group.ConclusionThis meta-analysis showed that CABG provided a better therapeutic effect than PCI in CKD patients with CAD when considering long-term prognosis. However, more prospective RCTs are needed to define the proper revascularization strategy for CAD patients with CKD.

Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study

BackgroundControversy exists regarding the advantages and risks of off-pump vs. on-pump coronary artery bypass grafting (CABG) for patients with diabetes. We therefore compare the early clinical outcomes of off-pump vs. on-pump procedures for diabetic patients with three-vessel disease.Materials and methodsWe conducted a retrospective analysis of clinical data obtained from 548 diabetic patients with three-vessel coronary artery disease who underwent isolated CABG between January 2016 and June 2020. To adjust the differences of baseline characteristics between the off-pump CABG (OPCAB) and on-pump CABG (ONCAB) groups, propensity score matching (PSM) was used. Following 1:1 matching, we selected 187 pairs of patients for further comparison of outcomes within the first 30 days after surgery.ResultsThe preoperative characteristics of the patients between the two groups were clinically comparable after PSM. The OPCAB group exhibited a significantly higher incidence of incomplete revascularization (27.3% vs. 14.4%; P = 0.002) compared with the ONCAB group. No differences were seen in mortality within 30 days between the matched groups (1.1% vs. 3.7%; P = 0.174). Notably, the OPCAB group had a lower risk of respiratory failure or infection (2.1% vs. 7.0%; P = 0.025), less postoperative stroke (1.1% vs. 4.8%; P = 0.032), and reduced postoperative ventilator assistance time (35.8 ± 33.7 vs. 50.9 ± 64.8; P = 0.005).ConclusionOPCAB in diabetic patients with three-vessel disease is a safe procedure with reduced early stroke and respiratory complications and similar mortality rate, myocardial infarction, and renal failure requiring dialysis to conventional on-pump revascularization.

Intravascular ultrasonography guided percuatneous coronary intervention with everolimus-eluting stents or bypass surgery for multivessel coronary artery disease: post-hoc analysis of the BEST study

Abstract Background Previous studies suggested that intravascular ultrasonography (IVUS)-guided percutaneous coronary intervention (PCI) improved clinical outcomes compared with coronary angiography (CAG)-guided PCI in complex coronary artery disease. Objectives We compared long-term clinical outcomes of IVUS-guided PCI with everolimus-eluting stent and coronary-artery bypass grafting (CABG) in multivessel coronary disease (MVD). Methods Among 880 patients with MVD enrolled in the BEST Extended Follow-up study, 333 patients underwent IVUS-guided PCI and 131 patients underwent CAG-guided PCI, which were compared with 401patients underwent CABG. The primary endpoint was the composite of death from any cause, myocardial infarction, or target-vessel revascularization during a median follow-up of 11.8 years (interquartile range, 10.6 to 12.5 years). Results During an extended follow-up, primary endpoint occurred in 75 patients (22.8%) in the IVUS-guided PCI group, in 58 patients (44.38%) in the CAG-guided PCI group, and in 95 patients (24.0%) in the CABG group. Compared with the CABG group, the IVUS-guided PCI group had a similar rate of primary endpoint (adjusted hazard ratio [HR], 1.013; 95% confidence interval [CI], 0.747-1.374; P=0.93), whereas the CAG-guided PCI group had a significantly higher risk of clinical events (adjusted HR, 2.231; 95% CI, 1.582-3.145; P&amp;lt;0.001). Similarly, whereas the IVUS-guided PCI group had similar rate (adjusted HR, 0.845; 95% CI, 0.605-1.181; P=0.324), the CAG guided PCI group had the significantly higher rate of the safety composite of death, stroke and myocardial infarction (adjusted HR, 2.016; 95% CI, 1.405-2.895; P&amp;lt;0.001) compared with the CABG group. However, both IVUS- and CAG-guided PCI groups had significantly higher rate of any repeat revascularization than CABG group. Conclusions In patients with MVD, IVUS-guided PCI appeared to be an safe and effective alternative to CABG. This study advocated the routine use of intravascular imaging during PCI for MVD.KM curve of outcomesPrimary and secondary outcome

The FRAGILE clinical trial: the impact of the coronary artery bypass graft in frailty

Abstract Background The exponential increase in the elderly population has been observed worldwide, and it implies a higher incidence of coronary artery disease and, consequently the need for coronary artery bypass graft (CABG). The growing number of elderlies is also related to frailty, a syndrome that affects at least 10% of the elderly population and is an exceedingly effective parameter for correlating with the adverse effects of aging. The impact of frailty concerning mortality and morbidity is well established however, there are no studies regarding the outcomes of CABG and its techniques in frail patients. Purpose To evaluate the impact of coronary artery bypass graft surgery in patient's frailty and compare the differences in the frailty index after a 6-month follow-up between the groups off-pump and on-pump. Methods This was a subanalysis of the FRAGILE trial, a brazilian multicenter, randomized, controlled clinical trial that analyzed 169 patients aged 60 years or older undergoing coronary artery bypass graft surgery with (on-pump) and without (off-pump) cardiopulmonary bypass. Using the Fried's Frailty Criteria, we classifed the patients into frail, pre-frail, and non-frail and also evaluated the five paramenters of this criteria. The patients were divided into two groups: the off-pump CABG group (n=87) and the on-pump CABG group (n=82), and compared unintentional weight loss, self-reported fatigue, physical activity level, grip strength, and gait speed before and after surgery, and between groups. The study was approved by the local Ethics Committee and all patients signed the informed consent. Results We observed an improvement in the frailty of patients undergoing CABG. Overall, over 50% of frail patients became pre-frail after CABG, and only 3% of the total patients were classified as frail after 6 months of surgery (Fig 1A). No patient was classified as non-frail preoperatively in both groups because it was one of the exclusion criteria. There is no difference between the groups off-pump and on-pump (Fig 1B). The total time of physical activity, the gait speed, and the self-reported fatigue were positively impacted regardless of surgical technique. However, grip strength and unintentional weight loss were improved only in the group that underwent off-pump CABG surgery. Patients reported practicing an average more time of exercises, improved gait speed, and claimed to be less fatigated compared to the before-surgery measurements. However, grip strength and unintentional weight loss were improved only in the group that underwent off-pump CABG surgery (Table 1). Conclusion CABG positively impacts patients' frailty after six months of surgery. Both techniques, on-pump and off-pump, showed positive results when comparing frailty features before and after CABG surgery. Nevertheless, the off-pump CABG was the only technique that played a role in improving grip strength and unintentional weight loss of patients after 6 months of surgery.Frailty classificationFrailty's parameters

Abstract 15300: Short-Term Outcomes in Different Revascularization for Acute Coronary Syndrome With Cardiogenic Shock Supported by Impella -Report From Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD Registry)

Introduction and Hypothesis: Percutaneous coronary intervention (PCI) has tended to be selected for the treatment of acute coronary syndrome with cardiogenic shock because of its ability of earlier and less-invasive therapy, though coronary artery bypass grafting (CABG) can perform complete revascularization. We hypothesized that Impella® support has the potential to make surgical treatment much safer because Impella® can improve hemodynamic state and could have the possibility to mitigate myocardial ischemia by unloading the left ventricle. Methods: The aim of study is to investigate if surgical revascularization is safe and effective treatment by comparing short-term outcome with different revascularization including PCI, CABG, and hybrid therapy (PCI followed by CABG). Of 1102 cardiogenic shock cases with Impella (994 cases in PCI, 48 cases in CABG, and 63 cases in Hybrid therapy) between February 2020 and December 2021 enrolled in the J-PVAD registry, short-term outcomes were compared between 62 propensity-matched cases between PCI (n=31) and CABG (n=31), as well as 68 matched cases between PCI (n=34) and hybrid therapy (n=34). Results: There was no difference in all-cause mortality between the PCI and CABG group as well as PCI and hybrid therapy group. The PCI group had a greater number of NYHA class≦2 at discharge than the CABG group (17 (54.8%) in the PCI group vs 10 (32.2%) in the CABG group, p=0.012). There was no difference in the number of NYHA class≦2 at discharge between the PCI and hybrid therapy group (18 (52.9%) in the PCI group vs 15 (44.1%) in the hybrid therapy group, p=0.12). Conclusions: CABG and hybrid therapy showed acceptable short-term outcome compared to PCI.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Chronic Total Occlusion of Coronary Arteries: A Systematic Review and Meta-Analysis

Introduction. Chronic total occlusion (CTO) of coronary arteries constitutes a substantial clinical challenge and has historically been managed through medical management and coronary artery bypass grafting (CABG). However, with the advancement in interventional technology, the success rate of percutaneous treatment has been significantly improved, and percutaneous coronary intervention (PCI) has emerged as a primary mode of treatment for CTOs, demonstrating remarkable clinical efficacy. The objective of this systematic review and meta-analysis is to evaluate and contrast the outcomes of PCI and CABG in patients with CTO. Methods and Results. A systematic search was conducted in the databases of PubMed, Embase, and Web of Science. The primary endpoints evaluated in this meta-analysis were the occurrence of major adverse cardiac events (MACE) and all-cause mortality. Secondary endpoints included myocardial infarction (MI), cardiac death, and the need for repeat revascularization. Nine studies, encompassing a total of 8,674 patients, were found to meet the criteria for inclusion and had a mean follow-up duration of 4.3 years. The results of the meta-analysis revealed that compared to CABG, PCI was associated with a lower incidence of all-cause mortality (RR: 0.78, 95% CI: 0.66–0.92; P  = 0.003) and cardiac death (RR: 0.55; 95% CI: 0.31–0.96; P  &lt; 0.05), but an increased risk of myocardial infarction (MI) (RR: 1.96; 95%CI: 1.07–3.62; P  &lt; 0.05) and repeat revascularization (RR: 7.13; 95% CI: 5.69–8.94; P  &lt; 0.00001). There was no statistically significant difference in MACE (RR: 1.11; 95% CI: 0.69–1.81; P  = 0.66) between the PCI and CABG groups. Conclusion. In the present meta-analysis comparing PCI and CABG in patients with chronic total occlusion of the coronary arteries, the results indicated that PCI was superior to CABG in reducing all-cause mortality and cardiac death but inferior in decreasing myocardial infarction and repeat revascularization. There was no statistically significant difference in MACE between the two groups.

The diagnostic accuracy of coronary angiography to detect left anterior descending artery myocardial bridging in coronary artery bypass grafting: a retrospective single-center study

Aims: The left anterior descending artery is the most involved vessel in the myocardial bridging of the coronary arteries. Revascularization of the left anterior descending artery (LAD) is considered an essential component of coronary artery bypass grafting (CABG) procedures. This study aims to evaluate the correlation between angiographic views of the coronary artery and intraoperative findings of the left anterior descending artery myocardial bridge (LADMB).&#x0D; Methods: The records of patients who underwent the CABG procedure between January 2015 and October 2022 were reviewed retrospectively. A total of 349 patients who had LADMB on coronary angiography (CAG) images and/or intraoperatively were evaluated. Patients were divided into two groups. The CAG group (n=50) consisted of patients with angiographic LADMB, and the CABG group (n=40) consisted of patients with LADMB that was detected intraoperatively. The correlation between myocardial bridge signs of the LAD in CAG and intraoperative observations was investigated.&#x0D; Results: In the coronary angiography group, 50 patients had signs of depression on coronary angiography, of whom 35 had LADMB intraoperatively. In the CABG group, 40 patients were found to have a myocardial bridge intraoperatively, and 5 had normal CAG images. The prevalence of LADMB was 11.5%. The sensitivity of CAG was 87.5%, the specificity was 95.15%, the positive predictive value was 70%, and the negative predictive value was 98.32%.&#x0D; Conclusion: The myocardial bridge signs of the LAD on CAG correlate with intraoperative observations with high sensitivity and specificity.

Preoperative diagnostic value of coronary CT angiography in acute Stanford type A aortic dissection involving the coronary arteries

To assess the diagnostic value of coronary computed tomography angiography (CCTA) in acute type A aortic dissection (ATAAD) with coronary artery involvement and to evaluate whether CCTA could provide potentially useful information for selecting the surgical method. Patients with ATAAD treated from January 2019 to December 2020 were reviewed retrospectively. Involvement of the coronary arteries based on CCTA findings were grouped into three major types and five subtypes. Interobserver and intraobserver diagnostic agreement for five subtypes were determined. The patients were divided into the coronary artery bypass grafting (CABG) and non-CABG groups, and the proportions of the five subtypes between the two groups were compared. A total of 95 patients were enrolled in this study. Interobserver and intraobserver diagnostic agreement were both substantial in the left and right coronary arteries. Overall, the proportions of the five subtypes of coronary artery involvement were significantly different between the two groups (p<0.001). The proportion of Type A was elevated in the non-CABG group compared with the CABG group (22.6% versus 71.9%); by contrast, the proportions of Type B1 (35.5% versus 14.1%), Type B2 (19.4% versus 10.9%), Type C1 (6.5% versus 0%), and Type C2 (16.1% versus 3.1%) were elevated in the CABG group. CCTA is reliable in evaluating coronary artery involvement by ATAAD. The present retrospective study indicated that CABG may be considered if the intimal flap disrupts the coronary orifice and causes luminal stenosis >50%, particularly Type B, or if an intimal tear occurs in the coronary orifice (Type C), which deserve further validation through prospective studies.

Catastrophic Health Expenditure and Out-of-pocket Payments for Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG)

Background: When households have high out-of-pocket (OOP) expenses, they are more likely to experience poverty and encounter catastrophic health expenditures (CHE). Heart disease is a significant cause of health decline and mortality. Objectives: This study aimed to provide essential knowledge about CHE and OOP for heart disease patients who underwent coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in Shiraz, Iran. Methods: This cross-sectional study with two prospective follow-ups was conducted in three heart surgery centers in Shiraz, Iran. The data were collected using the world health survey (WHS). Catastrophic health expenditures and OOP were asked from the most informed family member. Generalized estimating equation (GEE) modeling was employed to identify the main factors related to CHE and OOP. Binary distribution with logit link and gamma distribution with log link were used for CHE and OOP, respectively. The significance level was set at 0.05. Results: We found that OOP payment among patients who needed cardiovascular services in public-private partnership (PPP) hospitals was 76,953,100 Rials (R), equal to 2,506.78 $ (USD) (SD = 53,247,600 R/1,734.56 $) in the PCI group and 230,937,700 R equal to 7,522.89 $ (SD = 248,295,200 R/8,088.32 $) in the CABG group. This value in public hospitals was 15,083,800 R, equal to 491.36 $ (SD = 18,637,600 R/ 607.13 $) in the PCI group and 12,276,800 R, equal to 399.92 $ (SD = 11,131,900 R/ 362.63 $) in the CABG group. We also found that admission duration, age, type of hospital, and being currently a smoker were significant factors for OOP (P-value &lt; 0.05). During baseline assessment, we also found that the percentage of PCI patients that faced CHE was 95.56% and 47.92% in PPP and public hospitals, respectively. This value in CABG patients was 92.31% and 40.45%. Our study showed that the type of hospital and socioeconomic status were significant factors (P-value &lt; 0.05) that pushed a family facing CHE. Conclusions: The baseline CHE is very high in both PCI and CABG patients. Thus, the government should pay special attention to this issue. Further investigations are needed on factors affecting OOP and CHE.

Elective Cardiac Procedure Patients Have Low Preoperative Cardiorespiratory Fitness.

Preoperative cardiorespiratory fitness may influence the recovery after cardiac procedure. The aim of this study was to investigate the cardiorespiratory fitness of patients scheduled for elective cardiac procedures, using a six-minute walk test, and compare the results with a population-based sample of Finnish adults. Patients (n=234) awaiting percutaneous coronary intervention or coronary angiography, coronary artery bypass grafting, aortic valve replacement or mitral valve surgery performed the six-minute walk test. VO2max was calculated based on the walk test. The patients were compared to a population-based sample of 60-69-year-old Finnish adults from the FinFit2017 study. The mean six-minute walk test distances (meters) and VO2max (ml/kg/min) of the patient groups were: 452±73 and 24.3±6.9 (coronary artery bypass grafting), 499±84 and 27.6±7.2 (aortic valve replacement), 496±85 and 27.4±7.3 (mitral valve surgery), and 519±90 and 27.3±6.9 (percutaneous coronary intervention or coronary angiography). The population-based sample had significantly greater walk test distance (623±81) and VO2max (31.7±6.1) than the four patient groups (all p-values<0.001). All patient groups had lower cardiorespiratory fitness than the reference population of 60-69-year-old Finnish adults. Particularly the coronary artery bypass grafting group had a low cardiorespiratory fitness, and therefore might be prone to complications and challenging rehabilitation after the operation.