Coronary Artery Bypass Grafting Technique Research Articles

Learning Curve for No-Touch Vein Harvesting Technique in Off-Pump Coronary Artery Bypass Grafting

Introduction: The present study sought to analyze the learning curve of no-touch vein harvesting technique in off-pump coronary artery bypass grafting (CABG). Methods: Logarithmic curve fitting was used to analyze learning curves based on operative time for 160 patients that underwent no-touch CABG. The clinical data of 89 of these patients whose number of grafts was 3 were further retrospectively analyzed based on Cumulative Sum (CUSUM) analysis. Patients were divided into two groups, referring to the surgeon’s learning period and maturation period in chronological order. Perioperative outcomes were compared between two groups. Results: In this study, the learning curve for no-touch vein harvesting technique in off-pump CABG was quantitatively assessed in 51 cases through CUSUM analysis, and the results from logarithmic curve fitting corroborated these findings, indicating a significant milestone in proficiency gain for practitioners. Compared with patients in surgeon’s learning period, the median of the operative, Aorta-saphenous vein graft (SVG) anastomosis, and SVG checking time in the maturation period was significantly shorter (230 min vs. 250 min, p = 0.002; 11.5 min vs. 13.0 min, p = 0.025; 9.0 min vs. 11.0 min, p = 0.002). There was less first 48-h chest tube drainage, shorter postoperative hospital stay and rarer delayed incision healing in the leg in the late period compared with that in the early period (312.6 ± 140.7 mL vs. 401.0 ± 233.5 mL, p = 0.029; 11.0 d vs. 12.0 d, p = 0.026; 15.7% vs. 2.6%, p = 0.043). Conclusion: A cardiac surgeon mastered in CABG using the full-incision SVG harvesting method experienced a learning curve to gain early proficiency in no-touch CABG. In the initial learning period, Aorta-SVG anastomosis, bleeding check of SVG, and wound complications need to be paid more attention.

Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

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.

Recent Advances in Coronary Artery Bypass Grafting Techniques and Outcomes: A Narrative Review.

Coronary artery bypass grafting (CABG) has witnessed remarkable progress in recent years, driven by innovative techniques and refined approaches that have transformed patient outcomes and treatment paradigms. This review article comprehensively explores the latest advances in CABG techniques and their consequential impacts on patient outcomes. The advent of minimally invasive CABG techniques has revolutionized traditional surgical approaches. Robotic-assisted surgery and small thoracotomy methods offer reduced invasiveness, yielding shorter recovery times and improved patient satisfaction. Integrating CABG with percutaneous coronary intervention (PCI), hybrid procedures have emerged as a versatile strategy, providing tailored treatment solutions for complex coronary anatomies. The paradigm shift to off-pump CABG, which preserves the beating heart during surgery, has shown promise in reducing perioperative complications and neurocognitive deficits. Advances in graft selection, particularly the utilization of arterial grafts such as the internal thoracic artery and radial artery, have significantly enhanced graft patency rates and long-term survival. Adjunctive technologies, such as intraoperative imaging and graft flow assessment, have bolstered the precision of CABG procedures. Pharmacological agents have demonstrated their potential to improve graft outcomes. Surgical decision-making is now optimized based on patient characteristics and disease severity owing to the development of patient selection and risk stratification tools. Long-term results have also significantly improved. Patients undergoing CABG have higher survival rates, less angina, and better quality of life. Developing more resilient grafts through tissue engineering, using bioresorbable materials in graft fabrication, and using gene therapy to improve graft patency and overall cardiac recovery are all exciting future research directions. This review's summary of current developments in CABG procedures highlights their profoundly positive effects on patient outcomes. These developments can change the face of cardiovascular care by giving clinicians more tools to treat coronary artery disease (CAD) and enhance patients' quality of life.

Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting.

Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.

Early results of total arterial off-pump coronary artery bypass grafting using bilateral internal mammary arteries

Background: The optimal coronary artery bypass grafting (CABG) technique is still evolving. This study aimed to evaluate the early results of the total arterial off-pump technique using bilateral internal mammary arteries.
 Methods: This study was performed from May 2018 to May 2019 at a cardiac surgery center in India. It included 200 patients with coronary artery disease who had off-pump CABG using bilateral internal mammary arteries. The patients had follow-ups for three months. There were 50 females, and the mean age was 50±10 years.
 Results: Conversion to on-pump was required in one case (0.5%). The use of complete vein grafts was needed in three cases (1.5%), and vein graft extension was done for two cases (1%). Intra-aortic balloon pump was used in one case (0.5%). Postoperative re-exploration for bleeding was done in two cases (1%), and sternal dehiscence or deep infection occurred in two cases (1%). A pacemaker was used in one case (0.5%), and postoperative need for dialysis occurred in three patients (1.5%). No operative mortality or postoperative stroke was reported. Redo surgery was required in one patient (0.5%).
 Conclusions: Off-pump total arterial revascularization technique using bilateral internal mammary arteries could have an acceptable early outcome.

Pre-operative systemic inflammatory response index influences long-term survival rate in off-pump surgical revascularization.

Coronary artery bypass revascularization is still the optimal treatment for complex coronary artery disease with good long-term results. The relation between inflammatory activation in the post-operative period and the long-term prognosis was already postulated. The possible predictive role of preoperative inflammatory indexes after the off-pump coronary artery bypass grafting technique on long term survival was the aim of the study. Study population included 171 patients with a median age of 64 years (59-64) operated on using off-pump technique between January and December 2014. Patients enrolled in the current study were followed-up for 8 years. We conducted a multivariable analysis of pre-operative and post-operative inflammatory markers based on analysis of the whole blood count. The overall survival rate was 80% for the total follow-up period, while 34 deaths were reported (30-days mortality rate of 1%). In the multivariable analysis, a pre-operative value of systemic inflammatory response index (SIRI) >1.27 (HR = 6.16, 95% CI 2.17-17.48, p = 0.012) revealed a prognostic value for long-term mortality assessment after off-pump surgery. Preoperative inflammatory activation evaluated by systemic inflammatory reaction index (SIRI) possess a prognostic value for patients with complex coronary artery disease. The SIRI value above 1.27 indicates a worse late prognosis after off-pump coronary artery bypass (AUC = 0.682, p<0.001).

Experience, exposure, and attitudes regarding off-pump coronary artery bypass grafting techniques in US cardiothoracic surgical residents: Results of a survey

BackgroundWe sought to determine the current level of exposure to and interest in off-pump coronary artery bypass and beating heart surgery techniques regarding cardiothoracic surgical residents in the United States. MethodsAn email survey consisting of 6 questions was sent to all cardiothoracic surgery residents of approved cardiothoracic training programs in the United States. The survey was emailed using the Qualtrics XM cloud-based survey platform. When the email responses were received, the answers to the survey questions were tabulated by the Qualtrics software and the resident's institution and year of graduation from their residency was noted. ResultsOf 400 surveys sent, we received 99 responses for a response rate of 25%. A total of 78% of cardiothoracic surgery residents reported that they are at programs that do off-pump coronary artery bypass or beating heart surgery infrequently, noting that these cases are done in less than 5% of the coronary artery bypass graftings to which they are exposed. A total of 51% responded that they do not feel comfortable with off-pump coronary artery bypass grafting under any circumstances. A total of 49% reported some comfort with the technique with most of these respondents noting that they would do off-pump coronary artery bypass or beating heart surgery on a selective basis if the clinical situation arose and 4% plan to do off-pump coronary artery bypass routinely. Exposure to off-pump coronary artery bypass and beating heart surgery significantly correlated with future adoption of the technique by the cardiothoracic surgery residents. Cardiothoracic surgery residents in the lowest, middle, and highest terciles of exposure to off-pump coronary artery bypass and beating heart surgery plan to use these techniques 31%, 86%, and 75%, respectively, in selective cases when they are in independent practice. ConclusionsOver half of graduating cardiothoracic surgery residents do not feel comfortable with off-pump coronary artery bypass or beating heart surgery techniques. Exposure to these techniques in training correlates with comfort level and plans to use them in independent practice.

Post-operative incidences of atrial fibrillation in on-pump versus off-pump coronary artery bypass grafting

Objectives: Atrial fibrillation (AF) is one of the most common arrhythmias after coronary artery bypass grafting(CABG).Opinions divided regarding which of the two CABG techniques on-pump CABG or off-pump CABG has a lower incidence of post-operative AF. The aim of this study was to measure the incidence of post-operative AF in these techniques and its effect on the patients’ morbidity, mortality and hospital stay. Methods: We studied 60 consecutive medical records of patients that underwent on-pump and off-pump CABG .All our study patients underwent A 12-lead electrocardiogram (ECG) in the following situations: immediately after admission to the ward, after any event of arrhythmia either in the ward or in THE (ICU) and before discharge. We also used the regular monitor ECG cable for continuous, daily recording of patient rhythms. Results: (AF) occurred in two cases (6.25%) in the on-pump CABG group and in two cases (7.1%) in the off-pump CABG group ,(P=0.890). The mean length of hospital stay had been 6.4 days in the on-pump CABG group and 4.2 days in the off-pump CABG group (P value &lt;0.001). No mortality occurred. Conclusion: The incidence of post-operative (AF) was the same between on-pump and off-pump CABG.

The outcomes of ultrafiltration in on-pump versus off-pump coronary artery bypass grafting in patients with renal impairment

ObjectiveIn chronic kidney disease (CKD), using cardiopulmonary bypass (CPB) may contribute to renal dysfunction. Off-pump coronary artery bypass grafting (OPCAB) is one technique that preserved renal function, but the procedure may not be possible in certain situations. The ultrafiltration (UF) can remove excess fluid and inflammatory mediators that result from exposure to the CPB. Coronary artery bypass grafting (CABG) with UF could be an alternative way to preserve renal function.MethodA retrospective study of CKD patients who underwent CABG. The renal outcomes were compared between the patients who underwent CABG with UF and OPCAB. A repeated measure adjusted by propensity score was used for comparing the renal outcome. Univariable and multivariable logistic regression was used to identify the risk factors for acute renal failure (AKI) and adverse outcomes.ResultsFrom January 2009 and June 2020, there were 220 CKD patients, 109 (49.55%) patients underwent CABG with UF, and 111 (50.45%) patients underwent OPCAB. There were statistically significant differences in the change of the average level of creatinine between CABG with UF (increased + 0.09 mg/dl) and OPCAB (decreased − 0.05 mg/dl) (p = 0.043). Also, patients who underwent CABG with UF had a significantly increased risk for AKI (OR 5.38, 95%CI 1.09, 26.5).ConclusionThe UF adjunct technique in CABG with CPB tends to provide a lower protective effect for renal function and had a significantly higher incidence of post-cardiac surgery AKI when compared to OPCAB. If technically feasible, OPCAB would be a preferable choice for CKD patients.Study registration number: SUR-2562-06607/Research ID: 6607.

Incidence, predictors, and outcome for post-operative atrial fibrillation in Indian patients undergoing off-pump coronary artery bypass grafting-a prospective observational study.

Indian patients who undergo surgical revascularization are relatively younger than their Western counterparts and are predominantly revascularized using off-pump coronary artery bypass grafting (OPCAB) technique. They may therefore be at a reduced risk of developing post-operative atrial fibrillation (POAF). The aim of this study was to assess the incidence of POAF, measure its impact on outcomes, and identify the predictors for POAF in the Indian patients undergoing OPCAB. Besides, the ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons (STS) scores in predicting POAF was also assessed. In this prospective observational study, all patients undergoing isolated OPCAB in a single institution over a 12-month period were included. Patients undergoing re-operative surgery, emergency procedure, concomitant surgery, or those with history of previously diagnosed or treated atrial fibrillation were excluded. Logistic regression was performed to identify the predictors of POAF. The receiver operating characteristic (ROC) curve was used to determine the ability of EuroSCORE and STS scores to assess risk of developing POAF. We recruited 1108 patients in the study of which 88 (7.94%) patients developed POAF. Age (OR = 1.082, p < 0.001, 95%CI: 1.050-1.114), unstable angina (OR = 16.32, p = 0.036, 95%CI: 1.2-221.4), presence of diabetes mellitus (OR 1.781, p = 0.025, 95%CI: 1.074-2.955), left atrial size (OR 2.506, p = 0.001, 95%CI: 1.478-4.251), and presence of chronic renal failure (OR 8.7, p = 0.001, 95%CI: 2.4-31.53) were significant predictors of POAF. Both the EuroSCORE (p = 0.035) and the STS score (p = 0.001) were significantly higher in patients developing POAF. The area under the ROC curve for the EuroSCORE II was 0.62 and for the STS score was 0.64 suggesting satisfactory and similar discriminatory power of both the scores to predict POAF in these patients. POAF was associated with significantly increased adverse outcomes like stroke and prolonged hospital stay. In our study, the incidence of POAF was much lower (7.94%) than that reported previously. POAF significantly increased adverse outcomes and length of hospital stay. Both EuroSCORE II and STS scores had similar discriminating power in predicting POAF.

Ten-Year Outcomes of Off-Pump vs On-Pump Coronary Artery Bypass Grafting in the Department of Veterans Affairs

The long-term benefits of off-pump ("beating heart") vs on-pump coronary artery bypass grafting (CABG) remain controversial. To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. On-pump and off-pump CABG procedures. The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. ClinicalTrials.gov Identifier: NCT01924442.

Role of fractional flow reserve for invasive functional evaluation in surgical myocardial revascularization: available evidence and state of the art

Fractional flow reserve (FFR) is the ratio of distal to proximal pressure during maximal hyperemia and indirectly estimates the blood flow across a stenotic coronary artery and the related degree of myocardial ischemia. Several studies have investigated the role of FFR in the setting of percutaneous myocardial revascularization and further research is ongoing. However, current evidence on FFR-guided surgical myocardial revascularization is controversial and limited. The main scientific interest is to clarify whether FFR-guided coronary artery bypass surgery is associated with clinical benefits in terms of mortality, myocardial infarction, major adverse cardiovascular events, minimally invasive surgical access compared with sternotomy and off-pump surgery. Furthermore some data suggest that conduit selection for coronary artery bypass grafting and surgical technique might be affected by FFR value. The aim of this article is to review the most recent available evidence about FFR-guided coronary artery bypass grafting and to discuss clinical implications and future perspectives.

The Prognostic Significance of Neutrophil to Lymphocyte Ratio (NLR), Monocyte to Lymphocyte Ratio (MLR) and Platelet to Lymphocyte Ratio (PLR) on Long-Term Survival in Off-Pump Coronary Artery Bypass Grafting (OPCAB) Procedures.

Simple SummaryInflammatory processes are involved in the development and progression of coronary artery disease. Environmental factors, including hyperglycaemia, hyperlipidaemia, or smoking, promote endothelial disfunction. This process generates inflammation, which further exaggerates vascular wall injury. Immune cells migrate to the endothelium after its damage and promote platelets activation. Cardiac surgery activates inflammatory response. The knowledge on the intensity of immune cells activation may enable assessment of long-term consequences, including increased morbidity and mortality. The off-pump coronary artery bypass grafting technique allows to minimize systemic inflammatory reaction; however, some extent of the response still exists and may influence surgical results. The assessment of inflammatory response has undeniable value in coronary artery disease management. Several markers have been proposed; however, indices widely available from whole blood count are most valuable in daily practice. We evaluated and proposed the use of neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelets to lymphocyte ratio (PLR) in the prognosis of the long-term outcomes after off-pump coronary artery bypass grafting. Patients who present with abnormally increased values of pre-operative and post-operative NLR, MLR, and PLR should undergo meticulous follow-up controls, as they are burdened with a higher risk of death.Background: Cardiovascular diseases, apart from commonly known risk factors, are related to inflammation. There are several simple novel markers proposed to present the relation between inflammatory reactions activation and atherosclerotic changes. They are easily available from whole blood count and include neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), and platelets to lymphocyte ratio (PLR). The RDW results were excluded from the analysis. Method and results: The study based on retrospective single-centre analysis of 682 consecutive patients (131 (19%) females and 551 (81%) males) with median age of 66 years (60–71) who underwent off-pump coronary artery bypass grafting (OPCAB) procedure. During the median 5.3 +/− 1.9 years follow-up, there was a 87% cumulative survival rate. The laboratory parameters including preoperative MLR > 0.2 (HR 2.46, 95% CI 1.33–4.55, p = 0.004) and postoperative NLR > 3.5 (HR 1.75, 95% CI 1.09–2.79, p = 0.019) were found significant for long-term mortality prediction in multivariable analysis. Conclusion: Hematological indices NLR and MLR can be regarded as significant predictors of all-cause long-term mortality after OPCAB revascularization. Multivariable analysis revealed preoperative values of MLR > 0.2 and postoperative values of NLR > 3.5 as simple, reliable factors which may be applied into clinical practice for meticulous postoperative monitoring of patients in higher risk of worse prognosis.

The Influence of Risk Factors on Perioperative Results of Multivessel Coronary Artery Bypass Grafting Through the Left Anterior Minitoracotomy

Multivessel coronary artery bypass grafting (CABG) through the left anterior minitoracotomy using the technique of total coronary revascularization via left anterior thoracotomy (TCRAT) is routinely performed in our institution since July 2017. This technique is used in all patients regardless of the number of anastomoses, quality and location of coronary targets, body mass index, age, comorbidities and predicted postoperative risk.&#x0D; The aim. To present the results of 349 consecutive patients with isolated multivessel coronary artery disease who underwent minimally invasive CABG. To compare perioperative outcomes of minimally invasive CABG in patients with existent risk factors for CABG and to identify possible contraindications to the use of this CABG technique.&#x0D; Materials and methods. From July 2017 to January 2020, 357 consecutive patients were underwent multivessel CABG at our institution. Eight (2.3%) patients in whom CABG was performed through the median sternotomy were excluded from the study. The remaining 349 (97.7%) patients underwent complete myocardial revascularization through the left anterior minitracotomy using TCRAT technique (peripheral cannulation for cardiopulmonary bypass (CPB), cold blood cardioplegia). All the patients were divided into groups according to the presence of risk factors (obesity, old age, diabetes, risk of postoperative mortality greater than 2.0 calculated by EuroSCORE II scale) to analyze the impact of these factors on intraoperative and postoperative parameters.&#x0D; Results. Intra- and postoperative parameters in patients of all groups were within safe limits. There was no statistically significant difference between the patients older and younger than 70. Diabetic and obese patients had a longer total operation time (on average by 5%, p = 0.003 and 7%, p = 0.019, respectively), CPB time (on average by 8%, p = 0.002 and 11%, p = 0.0001, respectively) and intensive care unit stay (on average by 15%, p = 0.004 and 17%, p = 0.013, respectively) compared to the patients without these conditions. The patients with EuroSCORE II risk more than 2.0 were had longer main phase of the operation (on average by 12 minutes, i.e. 8%, p = 0.013), they required longer ventilation time (by 27%, p = 0.036), longer stay in the intensive care unit (by 23%, p = 0.0004), had a longer hospital stay (by 15%, p &lt; 0.0001), they were more likely to have acute kidney damage that required hemodialysis, and mortality was observed only in this group of patients. However, even in this group of severe patients, the incidence of complications and mortality did not exceed the predicted rates.&#x0D; Conclusions. The technique of minimally invasive CABG through the left anterior thoracotomy allow the possibility to avoid median sternotomy in 97.7% of patients with multivessel coronary artery disease.&#x0D; The technique of minimally invasive multivessel CABG through the left anterior thoracotomy is universal and does not require patient selection, because it can be used effectively and safely regardless of obesity, diabetes or old age.&#x0D; This technique can be performed in patients with any EuroSCORE II rate without the mortality rate increase.

Retrospective Evaluation of the Pre- and Postoperative Neutrophil-Lymphocyte Ratio as a Predictor of Mortality in Patients Who Underwent Coronary Artery Bypass Grafting.

We aimed to investigate the neutrophil-lymphocyte ratio (NLR) as a predictor of mortality in patients, who had undergone on-pump and off-pump coronary artery bypass grafting (CABG). This retrospective study comprised of 457 patients, who underwent CABG (323 on-pump and 134 off-pump) between January 2014 and October 2019. Preoperative, postoperative (PO) 1st hour, PO 1st day, and PO 5th day neutrophil-lymphocyte ratios were calculated. The patients were compared, according to demographic, laboratory, and clinical data. A receiver operating characteristics curve was applied to estimate a cut-off value of NLR for mortality. The on-pump group was older (P = 0.001), had a lower Euroscore II (P = 0.036), had a higher graft number (P < 0.001), intensive care unit stay (P = 0.001), and all PO NLRs, except preoperative NLR. There were 14 (3.06%) patients with mortality. Overall (N = 457), PO 1st hour (P = 0.001), PO 1st day (P < 0.001), and PO 5th day (P = 0.016) NLRs were considerably higher in patients with mortality. While none of the NLRs revealed a significant difference in the off-pump group, PO 1st hour (P = 0.004) PO 1st day (P < 0.001), and PO 5th day (P = 0.007) NLRs were higher in patients with mortality in the on-pump group. The increase in odds ratio of PO NLR was higher in patients with mortality in the overall group of PO 1st day and in the on-pump group of PO 1st hour and PO 1st day. The best combination of sensitivity and specificity was reached at a cut-off value of 6.4 for PO 1st hour NLR and 31.8 for PO 1st day NLR. As in indicator of inflammatory state, NLR readily can be used as a predictor of mortality. Regardless of the CABG technique used, postoperative 1st hour and postoperative 1st day NLR >6.4 and 31.8, respectively, are highly related to mortality.

Less invasive multivessel coronary artery bypass grafting: now is the time.

Less invasive multivessel coronary artery bypass grafting techniques have seen a progressive evolution over the last two decades. In their current state, they are easily reproduced and applicable to most patients requiring multivessel revascularization. The purpose of this review is to highlight their importance among a spectrum of evolving therapies and the accruing evidence in their favour. The first large dual center experience with minimally invasive coronary artery bypass grafting (MICS CABG) demonstrated the feasibility of performing multivessel surgical revascularization without the need for sternotomy or cardiopulmonary bypass. Subsequent angiographic studies to assess graft patency showed excellent early results. Studies comparing MICS CABG to conventional CABG demonstrate faster recovery while reducing hospitalization and cost. Multivessel less invasive coronary artery bypass grafting is basically limited to two procedures, MICS CABG and robotically assisted totally endoscopic CABG (TECAB). MICS CABG has evolved as a procedure that preserves the safety and efficacy of conventional CABG while avoiding the associated morbidity. It is reproducible, versatile and holds promise as the procedure of choice for multivessel coronary revascularization in the future. TECAB is likely the pinnacle of minimally invasive coronary surgery, the growth of which is hindered by widespread acceptance and industry involvement.

Off-pump coronary artery bypass grafting is safe and effective in patients with severe left ventricular dysfunction.

Severe left ventricular dysfunction (LVD) is associated with increased risk following coronary artery bypass grafting (CABG). Due to a dearth of reports on the choice of CABG technique in patients with LVD, this study aims to compare the outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) in such patients. Retrospective single-centre propensity-matched analysis comparing early- and long-term outcomes of OPCAB and ONCAB in patients with severe LVD. Primary outcome was long-term all-cause mortality. Between 2002 and 2014, a total of 1161 consecutive patients with severe LVD underwent isolated CABG [442 patients underwent OPCAB and 719 ONCAB (430 matched pairs)]. Incomplete revascularization was observed more frequently among OPCAB than ONCAB patients (35.3% vs 21.6%; P < 0.01). The overall 30-day mortality was 5% and was comparable between the matched groups [OR 0.64 (0.34-1.22); P = 0.18]. OPCAB patients had shorter median hospital stay (11 vs 12 days; P = 0.02) and lower packed red blood cell transfusion rates [2.7 (2.21-3.19) vs 4.4 (3.56-5.24); P < 0.01]. Estimated adjusted survival was 86.0% vs 85.8%, 69.1% vs 65.5% and 59.9% vs 49.1% at 1, 5 and 10 years for OPCAB and ONCAB patients, respectively (P = 0.99). Long-term risk of mortality was similar between groups [hazard ratio (HR) 0.94 (0.66-1.32); P = 0.7]. Incomplete revascularization was weakly associated with increased risk of long-term all-cause mortality [HR 1.33 (0.99-1.77); P = 0.05]. OPCAB is safe and effective in patients with severe LVD. Although incomplete revascularization is more commonly observed in patients undergoing OPCAB, it is not associated with increased late mortality.

Impact of Bilateral versus Single Internal Thoracic Artery Grafting on the Long-Term Survival in Adults: A Systematic Review.

ObjectiveTo analyse the survival of patients who had undergone bilateral internal thoracic artery grafting versus those with single internal thoracic artery grafting from the available literature. Moreover, this study will review the available literature regarding which of the two techniques seems to be the safest with long-term survival and reduced mortality rates.MethodsA literature search of the databases was conducted to retrieve studies that fall under the study design of cohort and randomized controlled clinical trials in English from January 2015 to July 2021. Finally, seven studies were selected: four cohort studies and three other from a randomized trial.ResultsThe cohort studies revealed that bilateral internal thoracic artery grafting is associated with lower mortality rates and better long-term survival outcomes than single internal thoracic artery grafting, while the ART randomized controlled clinical trials showed that there is no significant difference in mortality rates between both the coronary artery bypass grafting techniques. However, all studies concluded that bilateral internal thoracic artery grafting is associated with a higher frequency of deep sternal wound infections.ConclusionThe discrepancy in results between the cohort studies and randomized controlled clinical trial remains persistent. However, the stated advantages of bilateral internal thoracic artery grafting are not strong enough to convince surgeons to alter their practice and the wide magnitude of expectations from the ART study was reckoned as inadequate. This may well be due to the presence of limited criteria for bilateral internal thoracic artery grafting in identifying the impact on survival of extended arterial revascularization, and there is a new colossal expectation from the ongoing randomized trial based on multiple arterial grafting versus single arterial grafting.

Is hybrid coronary revascularization really beneficial in the long term?

Abstract OBJECTIVES This analysis aimed to compare both short- and long-term outcomes of hybrid coronary revascularization (HCR) with different techniques and coronary artery bypass grafting (CABG). METHODS Twenty-three studies were included, covering 10 468 different patients, among whom 2403 patients underwent HCR with either simultaneous or staged method and 8065 patients underwent CABG. RESULTS Compared with CABG, HCR had a statistically significant lower risk of stroke [odds ratio (OR) = 0.55, P = 0.049], major adverse cardiac and cerebrovascular events (OR = 0.69, P = 0.024) and blood transfusion (BT) (OR = 0.39, P &amp;lt; 0.001), whereas no significant differences were detected in mortality, myocardial infarction and repeat revascularization. A network meta-analysis showed that simultaneous HCR had significantly better outcomes in stroke (OR = 0.24, P = 0.01) and major adverse cardiac and cerebrovascular events (OR = 0.29, P &amp;lt; 0.001), and staged HCR had a significantly better outcome in BT (OR = 0.31, P &amp;lt; 0.001). According to the frequentist statistic results, simultaneous HCR had the highest probability of being the best treatment in terms of mortality (84%), stroke (97%), myocardial infarction (88%) and major adverse cardiac and cerebrovascular events (99%), whereas staged HCR had the highest probability of being the best in postoperative repeat revascularization (59%) and BT (83%). However, long-term results showed no significant difference between the HCR and CABG techniques. CONCLUSIONS HCR appears to be a feasible option for multivessel coronary artery disease patients. Compared to traditional CABG, HCR had lower risk of adverse events in the short term, but in the long term, survival rate and freedom from major adverse cardiac and cerebrovascular events rate were similar between groups.