Coronary Artery Bypass Grafting Research Articles

Comparison of outcomes of Impella-assisted high-risk percutaneous coronary intervention in patients with and without prior coronary artery bypass graft.

Limited data is available regarding in-hospital outcomes of patients undergoing high-risk percutaneous coronary intervention (HR-PCI) with Impella with and without a prior history of coronary artery bypass grafting (CABG). We performed a retrospective study from the Nationwide Inpatient Sample from year 2016 to 2020. We identified patients who underwent Impella and percutaneous coronary intervention on the same day and excluded those with cardiogenic shock. Subsequently, we stratified them into those with and without prior CABG. During the study period, 18 925 patients underwent HR-PCI. Among these, 2043 (10.8%) patients had prior CABG. Patients without prior CABG had a higher percentage of acute coronary syndrome at presentation (62.7 vs 56.1%, P = 0.008). The proportion of females was significantly higher in those without prior CABG (32.4 vs 21.7%, P < 0.001). On multivariate analysis, there was no statistically significant difference in the in-hospital mortality (5.8% in CABG vs 8.5% in non-CABG, P = 0.52). Patients without prior CABG had higher rates of acute kidney injury, major bleeding, and blood transfusions. There were no significant differences in rates of cardiac arrest, ventricular arrhythmias, acute stroke, coronary dissections, and coronary perforations. Those without prior CABG had a longer duration of hospitalization (6.8 vs 9.3 days, P < 0.001) and higher hospital charges ($292 267 vs $322 206, P < 0.035). Our study highlights that a history of previous CABG does not increase the risk of in-hospital mortality in patients undergoing Impella-assisted HR-PCI but is associated with reduced rates of complications.

Predicting severe multivessel coronary artery disease to guide access strategy in patients undergoing invasive coronary angiography.

Given radial artery conduits are increasingly utilized for coronary artery bypass grafting (CABG), avoiding transradial access (TRA) for invasive coronary angiography (ICA) may benefit patients who ultimately undergo CABG. We sought to predict the likelihood of severe multivessel disease (MVD) before ICA to guide this decision. This was a single-center study of 1485 patients with stable symptoms who underwent ICA. A model to predict severe MVD was developed. Relative importance analyses were performed to identify clinical characteristics most associated with the presence or absence of severe MVD. When predicting severe MVD, the model had a sensitivity of 70.3% and specificity of 71.8% (area under the curve = 0.7105). With a prevalence of 12.5% in our cohort, the model had a strong negative predictive value of 94.4%. Relative importance analyses showed factors most associated with the presence of severe MVD were a history of abnormal noninvasive tests, typical chest pain, aspirin use, insulin-dependent diabetes, increasing age, and a family history of coronary artery disease. Conversely, the absence of severe MVD was most associated with female sex, undergoing ICA as workup for either noncardiac or valve surgery, lung disease, atypical chest pain, and increased BMI. Clinical information available before ICA can risk stratify the likelihood of severe MVD and therefore aid in identifying patients that may need CABG and could stand to benefit from TRA avoidance. The potential benefits of maximizing radial artery conduit availability by avoiding TRA must be balanced against the risks of alternative access on an individual patient basis.

Reoperative minimal invasive off-pump coronary artery bypass graft in early left main stem stenosis following Modified Bentall procedure

AbstractSix months following modified Bentall procedure a patient presented with angina and acute ST depression. CT coronary angiogram revealed severe narrowing of the left main coronary artery. Minimal invasive off pump coronary artery bypass grafting avoided complex reoperative surgery and delivered an excellent clinical outcome.

Impact of zero-positive end-expiratory pressure on blood transfusion rates in off-pump coronary artery bypass surgery: a retrospective cohort study

BackgroundBleeding are common in cardiac surgery, with significant impacts on transfusion-related complications and patient prognosis. This study aimed to determine the differences in perioperative blood loss, transfusion rates, and the incidence of postoperative pulmonary complications (PPCs) with and without the use of positive end-expiratory pressure (PEEP) in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB).MethodsThis single-center, retrospective study included 106 adult patients undergoing coronary artery bypass surgery without cardiopulmonary bypass from January 2018 to March 2022. The patients were divided into two groups based on intraoperative ventilator settings: the zero-PEEP (ZEEP) group and the PEEP group. The primary outcome was the perioperative transfusion rate from the intraoperative period to postoperative 7 day. The incidence of PPCs was recorded for 1 week post-operatively. Logistic regression analysis was performed for statistical analysis.ResultsThe average PEEP in the PEEP group was 4.92 ± 0.42 cmH2O. Multiple regression analysis indicated that lower mean airway pressure during surgery tend to associate with intraoperative lower blood loss. The intraoperative transfusion rates in the ZEEP group were significantly lower than those in the PEEP group (ZEEP:14%, PEEP 38.4%, P = 0.02). Logistic regression analysis revealed that ZEEP (adjusted odds ratio [OR] 0.13, 95% confidence interval [CI] 0.04–0.78) and Society of Thoracic Surgeons(STS) scores (adjusted OR 2.31, 95% CI 1.53–3.49) were significantly associated with a reduced requirement for perioperative transfusions. No significant difference was observed between the two groups in terms of PPCs (p = 0.824). Atelectasis was the most common complication in both groups (ZEEP: 35.7%, PEEP: 40%, P = 0.832).ConclusionsZEEP and STS scores were associated with significantly reduced requirement for perioperative transfusion rates during elective OPCAB surgery. However, ZEEP did not significantly affect the incidence of PPCs.

Soluble Urokinase Plasminogen Activated Receptor in Type 2 Diabetes Mellitus Patients Undergoing Coronary Artery Bypass Grafting: A Prospective Interventional Cohort Study

Objectives: Elevated levels of soluble urokinase plasminogen activator receptor (suPAR) increase mortality in various systemic diseases. This has been shown amply in recent literature. The primary aim of the study was to investigate that whether this increase in suPAR levels have same results in type 2 diabetes mellitus (T2DM) patients undergoing coronary artery bypass grafting (CABG). We also aimed to observe the duration of mechanical ventilation and length of stay in the intensive care unit in these patients as our secondary aim. Materials and Methods: Blood samples of adult patients having T2DM admitted for elective on-pump CABG surgery were collected after induction of anesthesia before skin incision (T1) and 48 h post-cardiopulmonary bypass (CPB) (T2) from the year 2022 to 2023. The study was conducted on 196 patients of either sex of age at least 18 years with T2DM with the American Society of Anesthesiologists status III to IV. Patients were randomly divided into 2 groups with alternative allocation. Patients of the study group (n = 96) were measured suPAR, high-sensitivity C-reactive protein (hsCRP), and blood sugar, while patients of the control group (n = 100) were measured hsCRP and blood sugar only. Threshold suPAR levels for predicting mortality in the immediate post-operative period were assessed through receiver operating characteristic curves and optimal values decided using Youden’s Index. Results: There was a significant rise in suPAR and hs-CRP levels before the start of surgery and 48 h post-CPB (P &lt; 0.001). Conclusion: In patients with T2DM undergoing on-pump CABG, increased pre-bypass, and especially 48-h post-CPB, levels of suPAR and hsCRP predict more mortality.

A New Predisposing Factor for Postoperative Atrial Fibrillation: Tube Insertion Site.

The aim of this study is to compare the insertion sites of drainage tubes placed in the left thorax after elective coronary artery bypass grafting (CABG) surgeries. Patients were divided into two groups based on the site of tube insertion into the left hemithorax: those with a tube inserted from the subxiphoid region and those with a tube inserted from the left intercostal region. Comparative analyses between these two groups and factor analyses contributing to the outcome were performed. There were no significant differences observed in terms of age, gender, height, and weight among patients undergoing coronary artery bypass surgery based on the site of drain placement. Twelve patients (5.2%) required re-drainage procedures, with five (41.7%) for pneumothorax and seven (58.3%) for pleural effusion. Atelectasis was absent in 144 patients (62.1%) while present in 88 patients (37.9%). The frequency of atrial fibrillation (AF) was significantly higher in the group with intercostal drains. Additionally, pain scale scores were significantly higher in patients with intercostal drains. Path analysis revealed that the visual pain scale value played a full mediating role in the effect of the drain site on AF. The statistically significant occurrence of pain and higher rates of postoperative AF in patients with intercostal tube placement are noteworthy. We believe that in patients undergoing elective coronary artery bypass surgery, the drain placed in the left hemithorax should be inserted from the subxiphoid region, if there are no contraindications.

Pericoronary adipose tissue radiomics features as imaging markers for coronary artery disease risk assessment: insights from gene expression analysis

AimsThis study aimed to explore the correlation between radiomics features of pericoronary adipose tissue (PCAT) and gene expression in patients with coronary artery disease (CAD), with the goal of identifying novel imaging biomarkers for evaluating CAD.MethodsBetween November 2021 and May 2022, data were collected from 60 patients diagnosed with CAD who underwent coronary artery bypass grafting (CABG) and coronary computed tomography angiography (CCTA). Samples of PCAT, three additional adipose tissue types, and peripheral venous blood were analysed. Radiomics features of PCAT were extracted. Gene expression in adipose tissues and serum was quantified via RT-qPCR, immunohistochemistry and ELISA. The correlations between the radiomics features and genes were analysed.ResultsGene expression analysis revealed significantly elevated levels of CD31, MCP-1, and leptin in PCAT compared with other adipose tissues, and the radiomics features of PCAT have a strong correction with the expression of CD31 and MCP-1. At the systemic level, serum analysis revealed increased concentrations of TNF-α, IL-6, CD31, COL1A1, and resistin, with notable decreases in ADP in CAD patients relative to controls. Notably, CD31, ADP, IL-6, and resistin were significantly corrlated with PCAT texture features, whereas TNF-α was correlated with first-order features.ConclusionsOur findings demonstrated a significant correlation between PCAT radiomics features and gene expression patterns in CAD patients. These features effectively reflect the pathological state of tissues and hold potential as innovative imaging biomarkers. By leveraging PCAT radiomics, clinicians may gain valuable insights for advanced evaluation and management of CAD in later stages.

Early discharge with elevated C-reactive protein levels is safe after endoscopic-assisted coronary bypass grafting: Optimisation of postoperative care.

This study describes the perioperative kinetics of C-reactive protein in patients undergoing endoscopic coronary artery bypass grafting for single target vessel left anterior descending disease, with early postoperative discharge. From July 2021 to April 2024, patients were included in this single-centre retrospective study (N = 208), excluding C-reactive protein-modulating complications. Perioperative and 14-day follow-up C-reactive protein levels and clinical signs of infections were analysed. After endoscopic coronary artery bypass grafting, the C-reactive protein values on the first postoperative day were 44 [24-65] and 140 [88-200] mg/L at Day 3. Most patients were discharged after 3 days (64.4%), regardless of the level of C-reactive protein, and the majority experienced a return of C-reactive protein levels to baseline during follow-up, 6 [6-15] mg/L. Two patients had an infection requiring intervention and readmission (1.0%). The return of C-reactive protein to baseline levels at follow-up and the low incidence of clinical infections suggest that patients can be discharged safely, and prolonged hospitalisation is unnecessary. For perioperative care practitioners, these findings underscore the value of shorter hospital admissions in optimising resource use and improving patient flow, enhancing both patient outcomes and operational efficiency.

Ischemia-Induced Expression Status of Cofilin 1, CRSP2, HSP90, HSP27, and IL-8 in Epicardial Adipose Tissue and Single Cell Transcriptomic Profiling of Stromal Cells.

Epicardial adipose tissue (EAT) is a rich source of EAT-derived stromal cells (EATDS) which possess regenerative potential. CRSP2, HSP27, IL8, HSP90 and Cofilin 1 were detected in the secretome of left ventricular stromal cells under ischemia challenge. However, the association of these genes in the EAT and EATDS remain understudied. We aim to assess the status of cofilin 1, CRSP2, HSP27, IL8 and HSP90 in the EAT of myocardial infarction (MI) and Coronary Artery Bypass Graft (CABG) swine models and in vitro stimulated ischemic EATDS. Expression status of these proteins in EAT were assessed by immunostaining and in EATDS using qRT-PCR, immunostaining, and Western blot. EATDS phenotyping was performed using sc-RNAseq analysis. Cofilin 1 was increased while the other four genes were decreased in the CABG. IL8 and HSP90 were increased while CRSP2, HSP27 and cofilin 1 were decreased in the MI group. Similar trend was displayed in the expression of these genes in EATDS. Additionally, EATDS displayed versatile phenotypes at single cell resolution based on the differential expression of various gene signatures. The findings revealed novel insights into EAT/EATDS biology and further understanding regarding the EATDS sub-phenotypes would open novel avenues in translational cardiology.

Cardiorespiratory Fitness as a Risk Factor for Requiring Coronary Artery Bypass Grafting in a Veteran Population

Background: Regular physical activity is widely recommended to reduce the risk of coronary heart disease. Coronary artery bypass grafting is the gold standard treatment for severe multi-vessel coronary artery disease that has failed medical management. However, there is limited information on the relationship between cardiorespiratory fitness (CRF) and the likelihood of undergoing coronary bypass. This study aims to determine the association between CRF and the likelihood of requiring future coronary artery bypass in a US Veteran population. Methods: From a cohort of 740,075 United States Veterans who completed an exercise treadmill test between October 1, 1999, and September 3, 2020, with no evidence of cardiovascular disease, we identified 14,860 individuals who underwent a bypass more than six months after their fitness assessment. To assess the association between CRF and the risk of coronary bypass, we divided participants into CRF quintiles based on peak workload achieved: Least-fit: 4.7 ± 1.5 metabolic equivalents (METs) (n = 141,893); Low-fit: 7.2 ± 0.9 METs (n = 181,550), Moderate-fit: 8.5 ± 1.3 METs (n = 142,895), Fit: 10.5 ± 1.0 METs (n = 192,061) and High-fit: 13.5 ± 1.8 METs (n = 81,676). Cox proportional hazard models were used to calculate the risk of bypass across fitness categories. The models were adjusted for age, body mass index, race, cardiovascular medications, and cardiovascular risk factors. Results: The association between cardiorespiratory fitness and coronary artery bypass was inverse, independent, and graded. For every 1-MET increase in exercise capacity the risk of surgery was 10% lower (HR = 0.90; 95% CI: 0.89–0.91; p &lt; 0.001). Comparisons across CRF quintiles revealed that the risk for surgery was lower by 29% in the Low-fit group (HR = 0.71; 95% CI: 0.68–0.74; p &lt; 0.001), 37% in the Moderate-fit group (HR = 0.63; 95% CI: 0.60–0.66; p &lt; 0.001), 47% in the Fit group (HR = 0.53; 95% CI: 0.54–0.60; p &lt; 0.001), and 53% in the High-fit group (HR = 0.47; 95% CI: 0.43–0.50; p &lt; 0.001). Conclusions: Our findings support a graded, inverse relationship between CRF and the likelihood of undergoing future coronary bypass surgery. A moderate CRF level, achievable by most older individuals engaging in age-appropriate physical activity, was associated with a 40% lower likelihood of undergoing future coronary bypass.

Prevalence of Anxiety and Depression Among Patients with Coronary Artery Bypass Grafting (CABG) in Karnataka and Kerala

Prevalence of Anxiety and Depression Among Patients with Coronary Artery Bypass Grafting (CABG) in Karnataka and Kerala

Analysis of influencing factors for postoperative brain injury in patients with cardiac surgery

Objective To identify risk factors in people with heart disease prior to undergoing cardiac surgery and to provide a prediction model. Methods 106 patients who underwent cardiac surgery were selected by convenience sampling method. Case-control study design was used to divide them into control and observation groups according to whether there was postoperative brain injury. General demographic data, perioperative surgery, postoperative recovery, past medical history and preoperative conditions, laboratory test indicators were collected. Univariate and multivariate Logistic regression analyses were performed to select influencing factors. A nomogram model for predicting postoperative brain injury was established. Results Univariate Logistic regression analysis showed that age, female, stroke, diabetes mellitus, perioperative administration of dexmedetomidine, intraoperative use of cardiopulmonary bypass were related factors for postoperative brain injury(p < 0.05). Multivariate Logistic regression analysis showed that females, history of stroke, and intraoperative use of cardiopulmonary bypass were risk factors, and perioperative administration of dexmedetomidine was protective factor(p < 0.05). Nomogram model was established with an AUC of 0.847 and accuracy of 84.7%. Conclusion Preoperative stroke history and females are risk factors for brain injury after coronary artery bypass grafting under cardiopulmonary bypass, and perioperative use of dexmedetomidine is protective factor.

Changes in hemodynamic parameters with different anaesthesia induction agents in elderly patients with coronary heart disease

Background. Coronary heart disease (CHD) is one of the most common diseases in Ukraine and worldwide. Open myocardial revascularisation procedures require general anaesthesia with endotracheal intubation. Prevention of peri-intubation hypotension in elderly patients with CHD is relevant today. The purpose was to improve the safety of surgery in elderly CHD patients by determining the induction schedule for anaesthesia with minimal cardiodepressant and vasodilator effects. Materials and methods. A cohort prospective randomized study of 40 patients with ASA III–IV who underwent off-pump coronary artery bypass grafting. Their mean age was 67.00 ± 5.78 years. The participants were divided into 2 groups based on the type of induction agent: group 1 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg; group 2 — propofol 1.5 mg/kg, fentanyl 2.0 μg/kg, ketamine 0.5 mg/kg. Relaxation: pipecuronium bromide 0.1 mg/kg. Hemodynamic parameters were recorded at the following stages: 1) upon arrival to the operating room; 2) before it; 3) after intubation; 4) 25 minutes after intubation. Results. After the administration of induction drugs, a significant difference was observed only in mean arterial pressure (MAP): group 1 — 72.71 ± 4.76 %, group 2 — 81.29 ± 5.4 % of the baseline, p = 0.0001. At the third stage, a statistically significant difference between the groups was determined in three indicators: MAP (86.74 ± 8.82 %, 92.34 ± 7.26 %; p &lt; 0.05), stroke volume index (SVI) (99.91 ± 2.94 %, 109.63 ± 8.16 %, p &lt; 0.05), cardiac index (CI) (96.63 ± 11.77 %, 110.38 ± 12.37 %, p &lt; 0.05). At the fourth stage, a statistical difference between the groups was observed in MAP (74.87 ± 7.90 % in group 1 vs. 86.47 ± 6.07 % in group 2, p &lt; 0.05), SVI (87.09 ± 5.30 % in group 1 vs. 108.21 ± 8.32 % in group 2, p &lt; 0.05), ejection fraction (88.26 ± 3.58 % in group 1 vs. 106.89 ± 6.22 % in group 2, p &lt; 0.05), CI (79.59 ± 10.11 % in group 1 vs. 108.29 ± 9.95 % in group 2, p &lt; 0.05), systemic vascular resistance index (91.13 ± 9.34 % in group 1 vs. 77.86 ± 9.83 % in group 2, p &lt; 0.05). Conclusions. The addition of ketamine to the classic combination of propofol and fentanyl increases the effectiveness and reduces the percentage of possible potential complications by stabilizing hemodynamics during anaesthetic support for coronary artery bypass grafting in older patients with CHD.

Single cell transcriptomics profiling of the stromal cells in the pathologic association of ribosomal proteins in the ischemic myocardium and epicardial fat.

Sustenance of ischemia in the surviving cardiac tissue following myocardial infarction (MI) elicits a proinflammatory milieu resulting in subsequent pathological episodes. Also, the activation and release of ribosomal proteins under ischemic insults have been unveiled; however, their extra ribosomal functions are unknown. We identified the ribosomal proteins including RPL10A, RPL14, RPL30, RPS18, FAU-40 (RPS30), and RPSA (Laminin Receptor, LR) in the vesicles of ischemia challenged epicardial adipose tissue derived stromal cells (EATDS). The present study aimed to assess the association of these proteins in the epicardial adipose tissues (EAT) and left ventricular (LV) myocardium and isolated stromal cells (EATDS and LVSCs) from hyperlipidemic (HL), MI and coronary artery bypass graft (CABG) swine models. The findings revealed an upregulation of RPL10A, RPL14, RPL30, RPS18, RPS30, and RPSA in the LV tissues of CABG and HL swine with a concomitant reduction in the MI group. RPS30 displayed similar upregulation in EAT, whereas the expression of other ribosomal proteins was not significantly altered. Additionally, the ischemic LVSCs and EATDS displayed altered expression status of these genes compared to the control. Also, the RPS18 + , RPL30 + and RPSA + LVSCs favored ischemia and revealed similar anti-inflammatory and regenerative sub-phenotypes reflecting the protective/survival mechanisms. Further understanding regarding the underlying molecular mechanisms and functions of these ribosomal proteins offers immense translational opportunities in the better management of ischemic cardiac complications.

Optimization of the cardiac delirium index by including age, decrease in butyrylcholinesterase actitivity, preoperative HbA1c, and postoperative hemoglobin levels: results of a secondary analysis of a prospective observational study

IntroductionPostoperative delirium (POD) after cardiac surgery significantly affects the perioperative morbidity and mortality. Butyrylcholinesterase (BChE) is an enzyme primarily produced in the liver, which plays a crucial role in the hydrolysis of acetylcholine outside of neuronal synapses, referred to as extraneuronal hydrolysis. The integration of BChE activity into the cardiac delirium (CARDEL) index might increase its predictive power for identifying POD after cardiac surgery. Therefore, the primary aim of this study was to assess the applicability of the CARDEL index and determine whether integrating the BChE activity enables optimization of the predictive model.MethodsThis secondary analysis of a prospective observational study included patients undergoing elective coronary artery bypass graft surgery. BChE activity is expressed in units per liter (U/L), while the BChE drop refers to the percentage decrease in BChE activity from pre- to postoperative levels. POD risk factors were identified using multivariate regression analysis. The predictive power of the CARDEL index and an optimized model including BChE was calculated with receiver operating characteristic (ROC) analysis.ResultsOf 93 included patients, 20 (21.5%) developed POD. Elevated preoperative HbA1c [OR 2.5 (1.2–4.8), p = 0.01], a decrease in BChE activity [%, OR 1.1 (1.0–1.2), p = 0.04], age [1 (0.94–1.1), p = 0.55], and a postoperative hemoglobin change [OR 0.86 (0.78–0.96), p &amp;lt; 0.001] were identified as independent risk factors for POD. While the CARDEL index showed a moderate prediction of POD [AUCROC of 0.74 (0.60–0.87)], the optimization including BChE resulted in a significant prognostic improvement: AUCROC of 0.84 (0.72–0.94, p &amp;lt; 0.001).ConclusionDespite the small size of this derivation cohort, this study identified elevated HbA1c as the strongest risk factor for the development of POD, followed by a decrease in BChE activity, postoperative anemia, and age, respectively. By including these parameters to the CARDEL index, its predictive power for the identification of POD significantly improved in this derivation cohort. Moving forward, integrating these findings into clinical practice could enhance early risk stratification and targeted intervention for patients at high risk of POD. Therefore, further research should evaluate these results in a larger, external cohort.

Gender differences in the incidence of saphenous vein graft intervention

BackgroundSaphenous vein graft percutaneous coronary intervention (SVG PCI) following coronary artery bypass grafting (CABG) is commonly used procedure for patients presenting with acute coronary syndrome (ACS). Emerging evidence suggests gender-based differences influencing SVG intervention clinical outcomes. This study aimed to analyze the impact of gender and various patient characteristics, procedural intricacies, anatomical considerations, and perioperative factors as potential risk determinants for SVG failure post-CABG surgery.MethodsA retrospective, single-center, analysis was conducted on post-CABG patients at Barzilai Medical Center Ashkelon from 2010 to 2023 to assess gender-based differences in SVG PCI incidence.ResultsOf the 72 ACS patients undergoing SVG PCI, a notably higher incidence was observed in men. However, graft failure occurred earlier in women compared to men (13.50 ± 6.59 SD years vs. 22.13 ± 5.66 SD years). Women exhibited a 1.2 times higher likelihood of earlier PCI than men (OR 1.24 CI 1.077 to 1.487, p = 0.0066) after adjusting for age, smoking, diabetes, hypertension, and hyperlipidemia.ConclusionGender differences in the incidence of SVG PCI and graft failure denote the need for gender-tailored follow-up and early intervention to optimize graft patency and potentially enhance long-term clinical outcomes. Integrating gender-specific approaches into post-CABG management could significantly improve patient care and prognosis.

Long-Term Outcomes in Patients With Chronic Total Occlusion and Left Ventricular Systolic Dysfunction - A Single-Center Inverse Probability of Treatment Weighting Analysis.

The optimal treatment strategy for patients with coronary chronic total occlusion (CTO) and left ventricular systolic dysfunction (LVSD) remains unclear. This study investigated the long-term outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and medical therapy (MT) in this specific patient cohort. This retrospective cohort study included 987 consecutive patients with CTO and LVSD who met the inclusion criteria and underwent either CTO-PCI (n=277), CTO-CABG (n=222), or CTO-MT (n=488) between 2014 and 2020. The primary outcome was all-cause mortality during follow-up. Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and their components, including cardiovascular mortality, myocardial infarction (MI), stroke, unplanned revascularization, and hospitalization for heart failure. During a median follow-up of 5.3 years, 232 (23.51%) patients died from any cause. In the unadjusted analysis, CTO-MT was associated with worse long-term survival prospects. After inverse probability of treatment weighting and variable adjustment, CTO-PCI and CTO-CABG demonstrated significant reductions in the long-term risks of all-cause and cardiovascular mortality. Notably, CTO-CABG was associated with the lowest long-term risks of MACCE, MI, unplanned revascularization, and hospitalization for heart failure. For patients with CTO and LVSD, successful CTO revascularization significantly improved long-term survival compared with CTO-MT. CTO-CABG can be regarded as the optimal treatment modality for better long-term prognosis.

Silent Acute Myocardial Infarction and Anterolateral Papillary Muscle Rupture: A Rare Complication in Elderly Patients

Mitral regurgitation (MR) following acute myocardial infarction (AMI) is a common occurrence, often resolving without significant complications. However, severe MR leading potentially to acute heart failure or cardiogenic shock is rare. It can result from papillary muscle rupture (PMR) which is an extremely uncommon and life-threatening mechanical complication of AMI. We present a case of a 77-year-old male with a late-presenting high-risk acute coronary syndrome (ACS) complicated by acute MR due to anterolateral PMR. The patient exhibited atypical symptoms, including dyspnea and cough, and was diagnosed with a STEMI equivalent. Echocardiography revealed severe MR secondary to papillary muscle rupture. The patient underwent successful coronary artery bypass graft (CABG) and mitral valve replacement surgery. We discuss the risk factors, management and complications of papillary muscle rupture, emphasizing the importance of early recognition and intervention. This case underscores the potential for atypical ACS presentations in the elderly and highlights the significance of specific ECG patterns, such as ST segment elevation in leads aVR and/or V1. Despite advancements in therapy, the mortality associated with papillary muscle rupture remains high, underscoring the critical need for preventive measures and heightened clinical awareness

Non-Pharmacological Sleep Interventions after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

To synthesise up-to-date research evidence for non-pharmacological interventions to improve various sleep outcomes (e.g., sleep quality, duration) in postsurgical cardiac patients. Sleep disturbances are common amongst postsurgical cardiac patients, yet the effectiveness of non-pharmacological interventions in improving various sleep outcomes has not been comprehensively reviewed. A systematic review and meta-analysis guided by the PRISMA protocol. CINAHL, PubMed, PsycINFO, Embase, Web of Science, and Cochrane Library were searched for relevant research in May 2023. Included studies used a randomised controlled trial design that applied a non-pharmacological intervention for postsurgical cardiac patients and reported sleep as an outcome. For the meta-analysis, mean effect sizes were separately calculated for studies with regular and reverse-scored scales. Of 37 studies included, the most common cardiac surgery was coronary artery bypass graft. Most interventions were performed within the first postoperative week and assessed sleep quality outcomes using the Pittsburgh Sleep Quality Index. The interventions are categorised into five types. Human resource-based strategies emerged as the most effective. The meta-analysis of 27 eligible studies showed a mean effect size of 0.76 for studies with regular scoring scales and - 1.04 for those with reverse-scored scales, indicating medium to large effect sizes. Our findings provide strong evidence that non-pharmacological interventions, particularly human resource-based strategies, significantly improve sleep quality in postsurgical cardiac patients. The medium to large effect sizes underscore the clinical significance of these findings. Healthcare professionals should consider incorporating non-pharmacological interventions, especially human resource-based strategies, in care plans for postsurgical cardiac patients to improve sleep outcomes and promote recovery. These interventions should be tailored to individual physical and cultural differences for maximum effectiveness. Future research should evaluate the long-term effects of these interventions on various sleep outcomes, using both objective and subjective measures to provide a comprehensive assessment of their efficacy. This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Patient and public contributions were not required for this review.

Melatonin ameliorates inflammation and improves outcomes of ischemia/reperfusion injury in patients undergoing coronary artery bypass grafting surgery: a randomized placebo-controlled study.

To investigate the protective role of high dose melatonin concerning myocardial I/R injury and inflammation in patients undergoing on-pump coronary artery bypass grafting (CABG) surgery by evaluating IR/inflammatory biomarkers and clinical outcomes. This was a prospective; randomized; single-blinded placebo-controlled study conducted at cardio-thoracic surgery department of the Academy of the Cardiovascular and Thoracic Surgery, Ain Shams University. Eligible patients were randomly allocated to; melatonin-treated group (MTG) or placebo-treated group (PTG). The MTG (n = 17) received 60mg/day melatonin capsules daily starting 5 days before surgery in addition to the standard of care. PTG (n = 17) received placebo also 5 days before surgery plus standard of care. The levels of nuclear factor kappa beta (NF-κb) (primary outcome), tumor necrosis factor (TNF-α), cardiac troponins I, and IL-6 levels were all assessed for both groups at five time points: baseline before melatonin or placebo administration (T0), before cross-clamp application(T1), 5min after cross-clamp removal(T2), 6h after cross-clamp removal(T3) and 24h after cross-clamp removal(T4). Blood pressure was assessed at baseline, pre-operative and 24-hours post-operative. The Quality of recovery-40 score (QOR-40) was assessed for both groups on day 4 after surgery. TNF-α levels decreased in the MTG at T1(p = 0.034) versus PTG. At T2(p = 0.005), and T3(p = 0.04), TNF-α significantly increased in PTG versus MTG. Troponins significantly increased in PTG at T3 (p = 0.04) versus MTG. NF-κB levels declined at T1 (p = 0.013) and T2 (p = 0.0001) in MTG compared to PTG. IL-6 significantly increased in PTG versus MTG at T3 (p = 0.04). The QOR-40 score significantly decreased in MTG versus PTG. MTG had statistically significant decrease in DBP compared to the placebo group (p = 0.024). MTG had a statistically significant shorter intubation time than did the placebo group (p = 0.03). Melatonin 60mg was well-tolerated without any reported side effects. Our findings suggested that melatonin could ameliorate myocardial I/R injury after on-pump CABG and that this outcome was essentially correlated to its antiapoptotic and anti-inflammatory effects. Trial registration: ClinicalTrials.gov registration number NCT05552586, 9/2022.