Strategy Of Coronary Artery Bypass Grafting Research Articles

Physiology or Angiography-Guided Coronary Artery Bypass Grafting: A Meta-Analysis.

ResumoFundamento:Enquanto a angiografia coronária invasiva é considerada padrão outro para o diagnóstico da doença arterial coronariana (DAC), envolvendo os vasos coronários epicárdicos, a revascularização coronariana guiada por fisiologia representa uma prática padrão ouro contemporânea para a administração invasiva de pacientes com DAC intermediária. Porém, os resultados de longo prazo da avaliação da gravidade da estenose por meio da fisiologia, em comparação à angiografia como guia para a cirurgia de bypass – enxerto de bypass de artéria coronária (CABG), ainda são incertos. Esta metanálise visa avaliar os resultados clínicos de um CABG guiado por fisiologia em comparação a um CABG guiado pela angiografia.Objetivos:Buscamos determinar se os resultados entre um CABG guiado por fisiologia e os de um CABG guiado por angiografia são diferentes entre si.Métodos:Pesquisamos nas bases Medline, EMBASE e Cochrane Library. A última data de busca foi junho de 2020, e todos os estudos anteriores foram incluídos. Realizamos uma metanálise de razão de risco agrupado para quatro principais resultados: morte por todas as causas, infarto do miocárdio (IM), revascularização do vaso alvo (TVR) e eventos cardiovasculares adversos maiores (MACE). Valor de p <0,05 foi considerado estatisticamente significante. A heterogeneidade foi avaliada com o teste Q de Cochran, e quantificada pelo índice I2.Resultados:Identificamos cinco estudos incluindo um total de 1.114 pacientes. Uma metanálise agrupada não demonstrou diferenças significativas entre a estratégia da fisiologia e da angiografia para IM (razão de risco [RR] = 0,72; IC95%, 0,39–1,33; I2 = 0%; p = 0,65), TVR (RR = 1,25; IC95% = 0,73–2,13; I2 = 0%; p = 0,52), ou MACE (RR = 0,81; IC95% = 0,62–1,07; I2 = 0%; p = 1). A estratégia da fisiologia apresentou 0,63 vezes o risco de morte por todas as causas em comparação à estratégia da angiografia (RR = 0,63; IC95% = 0,42–0,96; I2 = 0%; p = 0,55).Conclusão:Esta metanálise demonstrou uma redução nas mortes por todas as causas quando usada a estratégia do CABG guiado por fisiologia. Porém, o curto período de acompanhamento, o tamanho da amostra pequeno dos estudos incluídos e a não-discriminação das causas de morte podem justificar essas conclusões. Estudos com períodos mais longos de acompanhamento são necessários para tirar conclusões mais robustas e definitivas.

Surgical myocardial revascularization outcomes in Kawasaki disease: systematic review and meta-analysis.

BackgroundKawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes.MethodsA systematic review using Medline, Cochrane, and Scopus databases was performed in February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain Monte Carlo methods.ResultsAmong 581 published reports, 32 studies were selected, including 1,191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITAs), saphenous veins (SV), and other arteries (gastroepiploic artery and radial artery) was compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI: 0.17–0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI: 0.00–0.73%, I 2 = 0%, tau2 = 0), with 63/1,108 and 56/1,108 patients, undergoing interventional procedures and surgical re-interventions during follow-up, respectively. Pooled prevalence was 3.97% (95% CI: 1.91–6.02%, I 2 = 60%, tau2 = 0.0008) for interventional procedures and 3.47% (95% CI: 2.26–4.68%, I 2 = 5%, tau2 <0.0001) for surgical re-interventions. Patients treated with arterial, venous, and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03, 95% CI: 0.00–0.30) and arterial CABG (HR 0.13, 95% CI: 0.00–1.78) showed reduced long-term mortality compared with venous CABG.ConclusionsCABG in KD is a safe procedure. The use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.

Coronary artery bypass graft surgery versus stenting for patients with chronic kidney disease and complex coronary artery disease: a systematic review and meta-analysis.

Background:The relative role of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stent implantation in patients with chronic kidney disease (CKD) and complex coronary artery disease (CAD) remains debatable due to the lack of randomized controlled trials (RCTs). We therefore performed this meta-analysis to compare the outcomes of the two strategies in CKD patients with multivessel and/or left main disease.Methods:Electronic databases including PubMed, EMBASE and Cochrane Library were comprehensively searched to identify the eligible subgroup analysis of RCTs and propensity-matched registries. The primary endpoint was all-cause mortality during the longest follow-up.Results:Five subgroup analyses of RCTs and six propensity-matched registries involving 26,441 patients were analyzed. Overall, the strategy of CABG was associated with lower risks of long-term mortality [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.74–0.93], myocardial infarction (OR, 0.41; 95% CI, 0.27–0.62), and repeat revascularization (OR, 0.25; 95% CI, 0.16–0.39) compared with PCI in CKD patients with complex CAD. However, CABG was slightly associated with higher risk of stroke than PCI (OR, 1.33; 95% CI, 1.00–1.77). Nonetheless, the higher stroke risk in the CABG group no longer existed during long-term follow-up (OR, 0.92; 95% CI, 0.37–2.25) (>3 years).Conclusion:This meta-analysis supports the current guideline advising CABG for patients with CKD and complex CAD. At the expense of slightly increased risk of stroke, CABG reduces the incidences of long-term all-cause death, myocardial infarction and repeat revascularization compared with PCI.

Long-term outcome after off-pump coronary artery bypass grafting: implication for public health

Abstract Background The debate on the benefits and limitations of off-pump (OPCAB) coronary artery bypass grafting (CABG) on long-term outcomes is not yet settled. This study aimed to compare the impact of OPCAB vs on-pump CABG on long-term outcomes and to evaluate possible public health implications linked to their use. Methods The PRIORITY project was planned to evaluate the long-term outcomes of two prospective multicenter studies on CABG conducted between 2002-2004 and 2007-2008. Data on isolated CABG were linked to administrative data in order to retrieve patients' late outcome. Time-to-event distributions were analyzed accordingly to primary event-type (death, major adverse cardiac events (MACEs)) using the Kaplan-Meier and the Cox proportional hazards methods. Results The study population consisted of 11 021 patients who underwent isolated CABG (27.2% OPCAB). The median follow-up time was 8.0 years (interquartile range 7.6-10.0 years). OPCAB had comparable late all-cause mortality to on-pump CABG (HR 0.94, 95%CI 0.85-1.03, p = 0.19), but it was associated to an increased risk of MACE (adjusted HR 1.14, 95%CI 1.06-1.23, p = 0.001). In particular, OPCAB had an increased risk of repeated revascularization with percutaneous cardiac intervention (PCI) (adjusted HR 1.33, 95%CI 1.16-1.53, p &amp;lt; 0.001) compared to on-pump CABG. Conclusions OPCAB does not affect long-term mortality, but it significantly increases the risk of MACEs. In particular, OPCAB had an increased risk of repeated revascularization with PCI. These findings may have important implications towards health resources allocation. Key messages Off-pump coronary artery bypass grafting strategy is associated with an increased long-term risk of MACE and repeated PCI. Off-pump strategy is mainly based on operator preferences and can have important implications in terms of healthcare costs.

P3609Optimization of the coronary artery bypass grafting strategy for left main coronary artery stenosis

P3609Optimization of the coronary artery bypass grafting strategy for left main coronary artery stenosis

Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy

BackgroundThe survival benefit of a strategy of coronary-artery bypass grafting (CABG) added to guideline-directed medical therapy, as compared with medical therapy alone, in patients with coronary artery disease, heart failure, and severe left ventricular systolic dysfunction remains unclear.MethodsFrom July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years.ResultsA primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test).ConclusionsIn a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone. (Funded by the National Institutes of Health; STICH [and STICHES] ClinicalTrials.gov number, NCT00023595.)

Comparing mortality and myocardial infarction between coronary artery bypass grafting and drug-eluting stenting in patients with diabetes mellitus and multivessel coronary artery disease: a meta-analysis.

IntroductionWe aim to compare the midterm outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in diabetic patients who had multivessel coronary artery diseases (CAD).Material and methodsA comprehensive literature search was conducted to identify the related clinical studies with a follow-up for 1 year at least. The endpoints were death, myocardial infarction, and major adverse cardiac and cerebrovascular events (MACCE).ResultsFinally, the analysis of ten studies involving 5,264 patients showed that patients with CABG had worse baseline characteristics, a higher rate of stable angina pectoris, a higher percentage of triple-vessel disease, higher incidence of chronic total occlusion and a higher SYNTAX score. However, there was no significant difference in mortality between the two groups. Additionally, the rates of myocardial infarction and MACCE were markedly decreased in the CABG group.ConclusionsThe strategy of CABG is better than PCI for diabetic patients with multivessel CAD. The CABG can significantly reduce the rates of myocardial infarction and MACCE and is comparable in mortality despite the worse baseline characteristics.

Optimal coronary artery bypass grafting strategy for acute coronary syndrome

Conventional coronary artery bypass grafting (CABG) using cardiopulmonary bypass and cardiac arrest is associated with higher mortality and morbidity rates in acute coronary syndrome (ACS) patients undergoing surgery. Although off-pump CABG (OPCAB) is beneficial for high-risk patients, its efficacy for ACS is unknown, with on-pump beating CABG an adjunctive method. We investigated the effects of OPCAB and on-pump beating CABG for ACS. We evaluated 121 consecutive patients with ACS (91 males, 30 females; mean age 69.5 ± 10.3 years) who underwent CABG since 2000. Seventy-five had unstable angina (UA) and 46 acute myocardial infarction (AMI) [non-ST elevation (NSTEMI): 22, ST elevation (STEMI): 24]. We assessed CABG for acute coronary syndrome under our primary OPCAB strategy, and compared perioperative status between UA and AMI patients. (1) Sixty-five (87 %) with UA underwent OPCAB, 8 on-pump beating CABG, and 2 conventional CABG. Conversion from OPCAB was seen in 4 patients. In-hospital mortality was 1.3 %. (2) All UA patients who had intra-aortic balloon pumping (IABP) underwent OPCAB. No patients with preoperative IABP experienced conversion from OPCAB. (3) In AMI patients, hospital mortality was higher (8.9 %) and the ratios for OPCAB, on-pump beating CABG, and conventional CABG were 39, 57, and 4 %, respectively. Mortality was exclusively seen in patients with STEMI who underwent conventional CABG. OPCAB might have beneficial effects for ACS patients with UA, while IABP was found essential for completing OPCAB. In AMI patients, on-pump beating CABG might be reasonable for avoiding conversion from OPCAB and ischemic perfusion injury.

The STICH Trial (Surgical Treatment for Ischemic Heart Failure): Mode-of-Death Results

This study sought to assess the effect of the addition of coronary artery bypass grafting (CABG) to medical therapy on mode of death in heart failure. Although CABG therapy is widely used in ischemic cardiomyopathy patients, there are no prospective clinical trial data on mode of death. The STICH (Surgical Treatment for Ischemic Heart Failure ) trial compared the strategy of CABG plus medical therapy to medical therapy alone in 1,212 ischemic cardiomyopathy patients with reduced ejection fraction. A clinical events committee adjudicated deaths using pre-specified definitions for mode of death. In the STICH trial, there were 462 deaths over a median follow-up of 56 months. The addition of CABG therapy tended to reduce cardiovascular deaths (hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.68 to 1.03; p = 0.09) and significantly reduced the most common modes of death: sudden death (HR: 0.73; 95% CI: 0.54 to 0.99; p = 0.041) and fatal pump failure events (HR: 0.64; 95% CI: 0.41 to 1.00; p = 0.05). Time-dependent estimates indicate that the protective effect of CABG principally occurred after 24 months in both categories. Deaths post-cardiovascular procedures were increased in CABG patients (HR: 3.11; 95% CI: 1.47 to 6.60), but fatal myocardial infarction deaths were lower (HR: 0.07; 95% CI: 0.01 to 0.57). Noncardiovascular deaths were infrequent and did not differ between groups. In the STICH trial, the addition of CABG to medical therapy reduced the most common modes of death: sudden death and fatal pump failure events. The beneficial effects were principally seen after 2 years. Post-procedure deaths were increased in patients randomized to CABG, whereas myocardial infarction deaths were decreased.

Composite versus conventional coronary artery bypass grafting strategy for the anterolateral territory: study protocol for a randomized controlled trial

BackgroundIn severe coronary artery disease, coronary artery bypass grafting (CABG) surgery is indicated to re-establish an adequate blood supply to the ischemic myocardium. Effectiveness of CABG surgery for symptom relief and mortality decrease should therefore depend on bypass graft patency. As bypass using a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis allows the best results in terms of graft patency, we designed a new surgical technique using a saphenous vein graft as a venous bridge to distribute the LIMA flow to the cardiac anterolateral territory. This novel strategy could extend the patency benefits associated to the LIMA. Other potential benefits of this technique include easier surgical technique, possibility to use saphenous vein grafts as vein patch angioplasty, shorter saphenous vein grafts requirement and reduced or eliminated manipulations of the ascendant aorta (and associated stroke risk).Methods/DesignBetween July 2012 and 2016, 200 patients undergoing a primary isolated CABG surgery using cardiopulmonary bypass with a LAD bypass graft and at least another target on the anterolateral territory will be randomized (1:1) according to 1) the new composite strategy and 2) the conventional strategy with a LIMA-to-LAD anastomosis and revascularization of the other anterolateral target(s) with a separated aorto-coronary saphenous vein graft. The primary objective of the trial is to assess whether the composite strategy allows non-inferior anterolateral graft patency index (proportion of non-occluded CABGs out of the total number of CABGs) compared to the conventional technique. The primary outcome is the anterolateral graft patency index, evaluated at one year by 256-slice computed tomography angiography. Ten years of clinical follow-up is planned to assess clinical outcomes including death, myocardial infarction and need for revascularization.DiscussionThis non-inferiority trial has the potential to advance the adult cardiac surgery field, given the potential benefits associated with the composite grafting strategy.Trial registrationClinicalTrials.gov: NCT01585285.

Reduction of Microembolic Signals with a Single-Clamp Strategy in Coronary Artery Bypass Surgery: A Pilot Study

Neurologic deficits are perhaps the most feared form of adverse outcome following cardiac surgery. Aortic trauma generates emboli and hence harbors the potential for neurocognitive injury. The single aortic clamp strategy of coronary artery bypass grafting (CABG) aims at reducing aortic manipulation. We hypothesized that this strategy will lead to a reduction in the number microembolic signals (MES) evaluated by transcranial Doppler (TCD), a surrogate measure of cerebral embolism. This pilot study was based on a prospective analysis of 22 patients in whom CABG was performed either with a single aortic clamp (SC group) or with a conventional multiple aortic side-clamp technique (MC group). The 2 groups did not differ with respect to mean age (60 + or - 6 years versus 65 + or - 8 years, not statistically significant [NS]) or EuroSCORE (2.1 + or - 1.5 versus 2.9 + or - 2, P = NS). The neurocognitive evaluation was based on the mini-mental state examination (MMSE). The preoperative MMSE values for the SC and MC groups were similar (29.5 + or - 0.5 and 29.2 + or - 1, respectively; P = NS). The total number of solid-particle embolization signals secondary to aortic manipulation was lower in the SC group than in the MC group (72 + or - 28 versus 127 + or - 69, P = .02). Neurocognitive performance was moderately reduced in both groups compared with preoperative values. This reduction was more pronounced in the MC group than in the SC group (22.2 + or - 4.1 versus 25.3 + or - 1.6, P = .02). One patient in the MC group had a reversible ischemic neurologic deficit (P = NS). There were no deaths or perioperative myocardial infarctions in either group. The single-clamp CABG strategy led to a reduction in MES, indicating a less pronounced embolic burden than with the conventional side-clamp CABG strategy. This strategy translated into a better performance in postoperative neurocognitive testing in the SC group of patients.

Frequent change of procedure during coronary artery bypass surgery suggests insufficient preoperative diagnostic strategy

We sought to evaluate how often and in what way surgeons change peroperatively their preoperative coronary artery bypass grafting strategy and to what degree these changes affect postoperative graft patency. A series of 109 patients with stable angina pectoris and at least one occluded coronary artery participated. The surgeon filled in a questionnaire pertaining to the planned localization and number of grafts. These estimates were compared to procedures actually performed and with the angiographic outcome six months after bypass surgery. Planned and actually inserted grafts disclosed a discrepancy in 22% of the patients, resulting in a lower or higher number of grafts than pre-operatively estimated. The difference in shift rates between the three sites, left anterior descending, left circumflex, and right coronary artery, was significant (P=0.014). Patency rates were highest when only preoperatively planned grafts were inserted. When shifts occurred, no matter in which direction, it resulted in a decreased patency rate of the inserted grafts. This finding was significant for LAD (P=0.037). Our findings might indicate the necessity of future studies with the use of scintigraphy or fractional flow reserve as physiological adjuncts to angiography for more targeted revascularization.

Brain magnetic resonance angiography-based strategy for stroke reduction in coronary artery bypass grafting

We have been using magnetic resonance angiography (MRA) preoperatively to identify patients at increased risk of stroke in coronary artery bypass grafting (CABG). Based upon the intracranial MRA findings, either the off-pump or the on-pump procedure was selected. We report the results of our MRA-based strategy of CABG in 140 consecutive patients. Intracranial arterial lesions were found in 90 patients (64%). The most affected arteries were internal carotid (48%), followed by vertebral (18%) and middle cerebral (16%). Using the MRA score describing the severity of intracranial atherosclerosis, 35 patients with a score of > or = 5 underwent off-pump, while 105 patients with a score of < 5 underwent on-pump CABG. In the off-pump group, the patient age was older, the incidence of abnormal preoperative brain CT was higher, and the MRA score was higher (6.0+/-1.1 vs. 1.2+/-1.3 points) than in the on-pump groups. Even though the risk was higher in the off-pump group, the clinical outcomes were not significantly different, including the hospital mortality and the incidence of stroke and additional coronary intervention. In conclusion, the brain MRA-based selection of off-pump CABG can contribute to prevention of stroke in neurologically high-risk patients.

Seven-year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status

OBJECTIVESTo compare seven-year survival in the Bypass Angioplasty Revascularization Investigation (BARI) patients randomly assigned to percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass grafting (CABG).BACKGROUNDThe primary results of BARI reported no significant difference in five-year survival between CABG and PTCA groups. However, among patients with treated diabetes mellitus, a subgroup not specified a priori, a striking difference was seen in favor of CABG.METHODSSymptomatic patients with multivessel disease (n = 1,829) were randomly assigned to initial treatment strategy of CABG or PTCA and followed for an average of 7.8 years. The intention-to-treat principle was used to extend the initial five-year BARI treatment comparisons.RESULTSKaplan-Meier estimates of seven-year survival for the total population were 84.4% for CABG and 80.9% for PTCA (p = 0.043). This difference could be explained by the 353 patients with treated diabetes mellitus for whom estimates of seven year survival were 76.4% CABG and 55.7% PTCA (p = 0.0011). Among the remaining 1,476 patients without treated diabetes, survival was virtually identical by assigned treatment (86.4% CABG, 86.8% PTCA, p = 0.72). The PTCA group had substantially higher subsequent revascularization rates than the CABG group (59.7% vs. 13.1%, p < 0.001); however, the changes between the five- and seven-year rates were similar for the two groups.CONCLUSIONSAt seven years, there was a statistically significant survival advantage for patients randomized to CABG compared with PTCA. Among patients with treated diabetes mellitus, the benefit of CABG over PTCA seen at five years was more pronounced at seven years; among nondiabetic patients, there was essentially no treatment difference.

Bypass angioplasty revascularization investigation: Patient screening, selection, and recruitment

Percutaneous transluminal coronary angioplasty (PTCA) is currently performed in many patients seeking care because of severe manifestations of multivessel coronary artery disease. Previously, the majority of such patients would have undergone coronary artery bypass grafting (CABG). No definitive evidence is available as to which initial revascularization strategy has the best long-term clinical and economic outcomes. The Bypass Angioplasty Revascularization Investigation (BARI) is the largest of several recent clinical trials that were designed to test the hypothesis that an initial strategy of PTCA in selected patients with multivessel coronary artery disease does not compromise long-term clinical outcome compared with an initial strategy of CABG. This report describes how patients were screened, selected, and recruited in BARI and how this process may influence the results and the interpretation of the trial. During the enrollment period, 25,200 patients undergoing diagnostic coronary angiography at the participating institutions or with off-site angiograms referred to BARI investigators were screened for BARI eligibility. Excluded from screening were patients without coronary artery disease, those with single-vessel disease, prior revascularization, primary congenital, valvular, or myocardial disease, and age > 80 years. Slightly more than half of the patients screened (12,670) were not clinically eligible for BARI because of left main disease, insufficient symptoms, emergency revascularization, or other logistic reasons. Thus, 12,530 patients had severe angina and/or ischemia and were clinically eligible for BARI. Nearly 33% of them (4,110) had multivessel disease, which was suitable for both PTCA and CABG.(ABSTRACT TRUNCATED AT 250 WORDS)