Coronary Artery Bypass Grafting Research Articles

Machine learning−derived multivariable predictors of postcardiotomy cardiogenic shock in high-risk cardiac surgery patients

ObjectiveTo develop a model for preoperatively predicting postcardiotomy cardiogenic shock (PCCS) in patients with poor left ventricular (LV) function undergoing cardiac surgery. MethodsFrom the Society of Thoracic Surgeons Adult Cardiac Database, 11,493 patients with LV ejection fraction ≤35% underwent isolated on-pump surgery from 2018 through 2019, of whom 3428 experienced PCCS. In total, 68 preoperative clinical variables were considered in machine-learning algorithms trained and optimized using scikit-learn software. ResultsCompared with patients with ideal recovery, those that did were younger (65 vs 67 years), more likely female, Black, with low LV ejection fraction (26.5 vs 28.9%), previous myocardial infarction, chronic lung disease, diabetes, reoperation, or advanced heart failure. Among those with PCCS versus ideal recovery, operative mortality was 27% (925/3428) versus 0.1% (5/8065). PCCS occurred more often after coronary artery bypass grafting with concomitant mitral valve repair or after longer perfusion and clamp times. Reliable preoperative PCCS predictors were more advanced cardiac, liver, and renal failure; frailty; and greater white cell count. Out of sample test set receiver operating curve achieved an area under the curve of 0.74 with acceptable calibration Hosmer-Lemeshow statistic χ2 = 1.33, P = .25. ConclusionsIn patients with severe LV dysfunction undergoing cardiac surgery, risk of PCCS is elevated by preoperative failure of other organ systems and complexity of the planned operation that prolongs myocardial ischemia and cardiopulmonary bypass. This risk calculator could serve as an important tool to preoperatively identify patients in need of advanced levels of support.

Prospective evaluation of treatment strategies in patients presenting with chronic total occlusion at coronary angiogram: rationale, design and baseline data of the PETS-CTO Registry.

Coronary chronic total occlusions (CTO) are associated with an increased chance of untreatable symptoms and worse prognosis. However, limited data are available about the interaction between treatment strategy, potential ischemia burden reduction and quality of life (QoL) improvement. Our prospective registry aims to assess the potentially different impacts of treatment strategies (coronary artery bypass grafting vs.. percutaneous coronary intervention vs. optimal medical therapy) on clinical outcomes and QoL domains. This article specifically focuses on describing the registry's rationale, design, and baseline characteristics of the enrolled patients. A total of 157 patients were enrolled. Every patient was evaluated for baseline symptoms, ischemic burden and QoL and allocated to a treatment arm. In 112 patients (71.3%) ischemia baseline assessment was performed and for 116 (73.9%) Seattle Angina Questionnaire (SAQ) was available. At baseline, a significant functional limitation was evident, especially in terms of angina stability (mean score 69±31%) and disease perception (mean score 69±27%). In 49.1% of patients, ischemia testing was positive. Patients with documented ischemia were generally more symptomatic (CCS class 1 36.4% vs.. 57.9%, P=0.023) and a significant inverse correlation between CCS class and SAQ domains was found. No association between ischemia burden and self-reported QoL scores was found. The PETS-CTO registry is the first prospective registry investigating the impact of different treatment strategies on QoL and ischemia burden in patients with CTOs. At baseline, the severity of symptoms was directly associated with ischemia burden and inversely associated with self-reported QoL evaluation.

S1176 Readmission Rates in the Inflammatory Bowel Disease Population After Coronary Artery Bypass Grafting: A Nationwide Analysis

S1176 Readmission Rates in the Inflammatory Bowel Disease Population After Coronary Artery Bypass Grafting: A Nationwide Analysis

Superior long-term patency of no-touch vein graft compared to conventional vein grafts in over 1500 consecutive patients

ObjectivesTo evaluate the long-term angiographic patency of saphenous vein grafts (SVG) harvested using the no-touch technique compared to the conventional technique.MethodsThis was a single-center, retrospective, cohort study. The inclusion criteria were individuals who underwent a CABG (coronary artery bypass grafting) between January 1995 and July 2020, and who successively needed a clinically-driven angiography. The primary endpoint was long-term patency. The secondary endpoints were differences in patency based on sub-group analysis (single vs. sequential graft, divided by target vessel).ResultsThe study included 1520 individuals (618 no-touch, 825 conventional and 77 arterial grafts). The mean clinical follow-up time was 8.4 years ± 5.5 years. The patency per patient was 70.7% in the no-touch grafts vs. 46.7% in the conventional grafts (p < 0.001, OR = 2.8). The graft patency was 75.9% in the no-touch grafts vs. 62.8% in the conventional grafts (p < 0.001, OR = 1.8).ConclusionsThe no-touch vein grafts were associated with statistically significantly higher patency at long-term compared to the conventional grafts.Clinical trial registrationNCT04656366, 7 December 2020.

Risk of mortality in patients requiring reoperative open-heart surgery

BackgroundImprovements in surgical techniques and perioperative care as well as increased patient life expectancies have led cardiothoracic surgeons to perform more complex operations, including reoperative open-heart surgeries. However, there is debate as to which patients are appropriate operative candidates for reoperative procedures. MethodsThis is a retrospective, single-center study of patients who underwent reoperative open-heart surgery via median sternotomy or thoracotomy over a 10-year period. Patients with previous ventricular assist device or heart transplant were excluded. Patients were stratified by age <65 years compared with age ≥65 years for analysis. Survival was assessed using Kaplan-Meier curves and log-rank tests. Multivariate analysis was performed with Cox proportional hazards regression. ResultsA total of 250 patients underwent reoperative open-heart surgery at our center from 2012 to 2022. In total, 176 patients underwent valve surgery, 53 underwent coronary artery bypass grafting, 31 underwent aortic surgery, and 29 underwent other operations. The overall mortality rate was 13.6% at 30 days and 21.2% at 1-year postoperatively. Patients ≥65 years old had a greater average survival compared with patients <65 years old (5.0 vs 4.1 years, P = .046). However, there were no differences in survival by age when patients were stratified by procedure, either coronary artery bypass grafting (P = .29) or valve surgery (P = .16). On multivariate analysis, reoperative valve surgery, intraoperative use of extracorporeal membrane oxygenation, and a greater number of reoperative surgeries were associated with lower survival. ConclusionPatients undergoing reoperative open-heart surgery are clinically complex and had lower survival with each subsequent reoperation.

Machine learning-based prediction of new onset of atrial fibrillation after mitral valve surgery

Abstract Background New-onset postoperative atrial fibrillation (nPOAF) is a common complication after cardiac surgery (30–50%), being associated with unfavorable long-term outcomes. Using the Society of Thoracic Surgeons National Adult Cardiac Database, we used machine learning (ML) to predict nPOAF and related 30-day outcomes following mitral valve (MV) surgery. A total of 27,856 MV operations were performed at 910 centers between 7/1/2017 and 6/30/2020 on patients without AF or a prior permanent pacemaker. The primary endpoint was nPOAF postoperatively. ML techniques utilized included penalized logistic regression, gradient boosting, decision trees, and random forests. Results The overall incidence of nPOAF was 35.4% and that of new pacemaker insertion was 5.6%. Patients who developed nPOAF were older (67 ± 10 vs 60 ± 13 years), had more mitral valve stenosis (14.1% vs 11.7%), and hypertension (72.1% vs 63.3%). They underwent more mitral valve replacement (39.1% vs 32.7%) and coronary artery bypass grafting (23.9% vs 16%). For predicting nPOAF, ML methods offer sensitivity, specificity and precision superior to logistic regression. The accuracy rate was identical with penalized and non-penalized logistic regression (0.672). Conclusions Predicting nPOAF and its short-term sequelae following MV surgery remains highly challenging. Machine learning methods offer a moderate degree of improvement in predicting nPOAF even in large national-level studies, in the absence of multi-modal data, such as real-time wearables data, electrocardiograms, heart rhythm monitoring, or cardiac imaging.

Coronary Artery Bypass Grafting: Past and Future.

Coronary Artery Bypass Grafting: Past and Future.

TCT-24 Prognostic Value of Functional Incomplete Revascularization by Quantitative Flow Ratio for Valve Surgery With Coronary Artery Bypass Graft

TCT-24 Prognostic Value of Functional Incomplete Revascularization by Quantitative Flow Ratio for Valve Surgery With Coronary Artery Bypass Graft

TCT-286 Impact of Dual Antiplatelet Therapy on Secondary Revascularization due to Native Vessel Disease Progression vs Graft Failure After Coronary Artery Bypass Graft

TCT-286 Impact of Dual Antiplatelet Therapy on Secondary Revascularization due to Native Vessel Disease Progression vs Graft Failure After Coronary Artery Bypass Graft

Impact of Multi versus Single Arterial Coronary Bypass Graft Surgery on Postoperative Atrial Fibrillation

The effect of multi-arterial (MA) versus single arterial (SA) coronary bypass graft surgery on postoperative atrial fibrillation (POAF) was not investigated. From May 2017 to May 2024, the patients with CYP2C19*2 or *3 allele receiving coronary artery grafting and post-operational aspirin 100 mg/day and clopidogrel 75mg/day were retrospectively reviewed and assigned into MA or SA group. The primary endpoint was the incidence rate of POAF in first week. The secondary endpoints were POAF burden, platelet aggregation, systemic immune-inflammation (SII) index and heart rate variability (HRV). The study included 58 cases in MA group and 174 cases in SA group. The incidence of POAF was 17% in MA group contrasting with 42% in SA group (hazard ratio: 0.353; 95% confidence interval: 0.218 to 0.569, P=0.0012). A lower POAF burden was observed in MA group than that in SA group (2 h [1, 5] versus 10 h [6, 20], P=0.02). Platelet aggregation (arachidonic acid, 46%±10% vs. 56%±8%, P<0.01; adenosine diphosphate, 58%±17% vs. 75%±13%, P<0.01) and inflammation response index (neutrophil-lymphocyte ratio, 26±4 vs. 28±5, P=0.006; SII index, 5019±771 vs. 5382±1204, P=0.032) was notably lower in MA group than those in SA group at one day after CABG. Holter electrocardiogram showed a higher HRV value in standard deviation of normal-to-normal RR intervals, and decreased low-frequency/high-frequency ratio in MA group. In conclusion, MA was associated with a lower incidence rate of POAF, and paralleled with a lower AF burden, platelet aggregation, inflammation reaction and a higher parasympathetic nerve tone compared with SA regimen.

Impact of functional recovery on patients having heart surgery.

To describe the results of a program developed to manage institutional postacute care (IPAC) (postacute skilled nursing, inpatient rehabilitation facility, and long-term acute care) in a CMS Bundled Payments for Care Improvement (BPCI) project for coronary artery bypass graft (CABG) surgery. We compared pre- and postutilization patterns during a 3-year period by evaluating risk-adjusted national, state, and other BPCI participant comparisons using a difference-in-differences (DID) analysis in a large urban community tertiary center with a CABG surgery program. Included in the analysis were all Medicare patients receiving CABG surgery at the institution (n = 504), across the nation (n = 213,423), and at other BPCI institutions (n = 4939). The intervention included (1) use of a standardized tool for evaluation and prognostication of patient placement, (2) programmatic changes to manage patient functional recovery, and (3) patient and family engagement in postacute placement and functional recoveryplan. Physical therapist/occupational therapist time with patients who had undergone CABG surgery increased by more than 179% between the pre- and postintervention periods. This was associated with a 41.2% and 51.6% decline in IPAC use at the institution on an observed basis and adjusted basis, respectively. DID comparison demonstrated a 14.40% (95% CI, -19.30% to -9.60%) greater reduction at the target hospital than at other participating BPCI hospitals. A strong association exists between a focused patient functional recovery program and IPAC use reduction after CABG surgery. Using a structured approach to clinical analytics and hypothesis testing of redesign efforts when managing postacute care populations removes waste from care delivery.

The Impact of Remote Ischemic Preconditioning on Inflammation Markers in Patients Undergoing Coronary Artery Bypass Grafting.

This study aimed to investigate if remote ischemic preconditioning reduces the inflammatory process on patients undergoing coronary artery bypass grafting (CABG). We conducted a case-control study involving 80 patients, half of whom underwent ischemic preconditioning for severe coronary artery disease (CAD) and subsequently underwent CABG. We assessed interleukin (IL)-1 and IL-6 levels using the enzyme-linked immunosorbent assay (ELISA) method, high-sensitivity troponin I (hsTnI) using chemiluminescent immunoassay (CLIA), and C-reactive protein (CRP) using the turbidimetric method at three key time points: before surgery (visit 1 or V1), immediately postoperatively (visit 2 or V2), and 1 week postoperatively (visit 3 or V3) in all subjects. Ischemic preconditioned patients showed a significant decrease in proinflammatory markers (IL-1, IL-6) but not in CRP or hsTnI. This study demonstrated that remote ischemic preconditioning significantly reduced the levels of specific proinflammatory markers (IL-1 and IL-6), which may suggest general systemic protection. However, it did not demonstrate cardioprotection per se, as evidenced by the absence of a statistically significant decrease in hsTnI level.

Outcomes of Surgical Valve Replacements for Radiation-Induced Valvulopathy

Objective(s)Cancer patients who receive radiation therapy to the thorax often develop radiation-induced heart disease (RIHD) decades later. Prior chest radiation is associated with elevated perioperative risk of complications and mortality following cardiac surgery. Whether the type of valve (mechanical vs. bioprosthetic) used affects outcomes in patients with RIHD is unknown. MethodsThis retrospective review analyzed the characteristics and post-operative outcomes of patients with a prior history of chest radiation for Hodgkin or non-Hodgkin lymphoma who underwent surgical valve replacement at a single institution between 2000 and 2021. Both 30-day peri-operative outcomes and long-term survival were assessed. ResultsMechanical valve patients tended to be younger, have more valves replaced, and have undergone prior coronary artery bypass grafting (CABG) than bioprosthetic valve recipients. Valve type alone did not alter perioperative complications or overall survival. Median survival was 11.0 years in mechanical and 10.9 years in bioprosthetic valve patients (P = 0.930). Twelve patients underwent valve reinterventions (6 mechanical, 6 bioprosthetic), and three underwent transplant. Single valve (AV or MV) recipients fared better with median survival of 13.3 years compared to 6.2 years in those who underwent combined AVR+MVR (P<0.0001). ConclusionsPatients with RIHD who undergo surgical valve replacement have similarly suboptimal short- and long-term outcomes regardless of mechanical vs. bioprosthetic valve type. Those who required combined aortic and mitral valve replacement had especially high 10-year overall mortality. Further investigation in a larger dataset including transcatheter approaches is warranted.

Stress CMR Perfusion Imaging in the Medicare-Eligible Population: Insights From the SPINS Study.

Patients aged ≥65 years account for a disproportionately large portion of cardiovascular (CV) events and pose a challenge for noninvasive detection of coronary artery disease. This study sought to determine the prognostic value of stress cardiac magnetic resonance (CMR) in a Medicare-eligible group of patients in a multicenter setting in the United States. From a multicenter U.S. registry, the study identified patients aged≥65 years who were referred for stress CMR for evaluation of myocardial inducible ischemia. The primary outcome was defined as CV death or nonfatal myocardial infarction, whereas the secondary outcome was defined as any primary outcome, hospitalization for unstable angina, hospitalization for congestive heart failure, and unplanned late coronary artery bypass grafting. The associations of CMR findings with CV outcomes adjusted to clinical risk markers and health care cost spending were determined. Among 1,780 patients (aged 73 ± 5.7 years; 46% female), study investigators observed 144 primary eventsand 323 secondary events, over a median follow-up of 4.8 years. The presence of inducible ischemia and late gadolinium enhancement (LGE) was associated with incrementally higher event rates. Patients with neither inducible ischemia nor LGE experienced a<1% annualized rate of primary outcome. In a multivariable model adjusted for CV risk factors, inducible ischemia and LGE maintained an independent association with primary (HR: 2.80 [95%CI: 1.93-4.05]; P< 0.001; and HR: 1.85 [95%CI: 1.21-2.82]; P = 0.004, respectively) and secondary (HR: 2.46 [95%CI: 1.90-3.19]; P< 0.001; and HR: 1.72 [95%CI: 1.30-2.27]; P< 0.001, respectively) outcomes. Rates of revascularization, as well as downstream costs for patients without CMR-detected inducible ischemia, remained low throughout the follow-up period. In a multicenter cohort of Medicare-eligible older patients, stress CMR was effective in providing risk stratification. (Stress CMR Perfusion Imaging in the United States [SPINS] study; NCT03192891).

TCT-995 Comparison of Left Radial vs Femoral Artery Access for Coronary Angiography and Percutaneous Coronary Intervention After Coronary Artery Bypass Graft Surgery

TCT-995 Comparison of Left Radial vs Femoral Artery Access for Coronary Angiography and Percutaneous Coronary Intervention After Coronary Artery Bypass Graft Surgery

Balancing Relief and Pain: Effects of COX-2 Inhibitor Valdecoxib

Valdecoxib, a selective cyclooxygenase-2 (COX-2) inhibitor, was initially acclaimed for its gastrointestinal safety and effectiveness in managing chronic inflammatory conditions and pain. It reduced gastrointestinal complications compared to other anti-inflammatory drugs, benefiting patients with complex medication regimens. The injectable form, parecoxib, was seen as promising for acute post-surgery pain management. However, clinical trials in high-risk cardiovascular patients, particularly those undergoing coronary artery bypass grafting, revealed increased risks when using higher doses of parecoxib. These findings led to the re-evaluation of valdecoxib’s safety profile and its subsequent market withdrawal due to cardiovascular concerns and reports of serious skin reactions. Despite its withdrawal, valdecoxib has garnered interest for repurposing in other conditions. Its pharmacodynamic and pharmacokinetic properties suggest potential in qualifying palmitate-induced insulin resistance in type 2 diabetes and inhibiting matrix metalloproteinases for wound healing. Its efficacy against SARS-CoV-2 highlights drug repurposing strategies for health crises like COVID-19. Valdecoxib's established success in arthritis, dysmenorrhea, and postoperative pain, along with its potential in treating glaucoma, underscores the value of repurposing existing drugs for new therapeutic purposes. In conclusion, valdecoxib exemplifies the balance between drug safety, clinical utility, and innovative repurposing. The aim of this study is to fully harness drug potential in medical science through a concerted effort made by the scientific community, regulatory bodies, and industry stakeholders to navigate the technological and regulatory hurdles.

Outcomes with revascularisation versus conservative management of participants with 3-vessel coronary artery disease in the ISCHEMIA trial.

Whether revascularisation (REV) improves outcomes in patients with three-vessel coronary artery disease (3V-CAD) is uncertain. Our objective was to evaluate outcomes with REV (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) versus medical therapy in patients with 3V-CAD. ISCHEMIA participants with 3V-CAD on coronary computed tomography angiography without prior CABG were included. Outcomes following initial invasive management (INV) with REV (PCI or CABG) versus initial conservative management (CON) with medical therapy alone were evaluated. Regression modelling was used to estimate the outcomes if all participants were to undergo prompt REV versus those assigned to CON. Outcomes were cardiovascular (CV) death/myocardial infarction (MI), death, CV death, and quality of life. Bayesian posterior probability for benefit (Pr [benefit]) for 1 percentage point lower 4-year rates with REV versus CON were evaluated. Among 1,236 participants with 3V-CAD (612 INV/624 CON), REV was associated with lower 4-year CV death/MI (adjusted 4-year difference: -4.4, 95% credible interval [CrI] -8.7 to -0.3 percentage points, Pr [benefit]=94.8%) when compared with CON, with similar results for PCI versus CON (-5.8, 95% CrI: -10.8 to -0.5 percentage points, Pr [benefit]=96.4%) and CABG versus CON (-3.7, 95% CrI: -8.8 to 1.5 percentage points, Pr [benefit]=84.7%). Adjusted 4-year REV versus CON differences were as follows: death -1.2 (95% CrI: -4.7 to 2.2) percentage points, CV death -2.3 (95% CrI: -5.5 to 0.8) percentage points, with similar results for PCI and for CABG. The Pr (benefit) for death with REV (PCI or CABG) versus CON was 49-63%. The adjusted 12-month Seattle Angina Questionnaire-7 summary score differences favoured REV: REV versus CON 4.6 (95% CrI: 2.7-6.4) percentage points; PCI versus CON 3.6 (95% CrI: 1.2-5.8) percentage points and CABG versus CON 4.3 (95% CrI: 1.5-6.9) percentage points with high Pr (benefit). In participants with 3V-CAD, REV (either PCI or CABG) was associated with a lower 4-year CV death/MI rate and improved quality of life, with similar results for PCI versus CON and CABG versus CON. The differences in all-cause mortality between REV and CON were small with wide confidence intervals. (ClinicalTrials.gov: NCT01471522).

TCT-291 Impact of Preoperative Quantitative Flow Ratio on Long-Term Coronary Artery Bypass Grafts Patency

TCT-291 Impact of Preoperative Quantitative Flow Ratio on Long-Term Coronary Artery Bypass Grafts Patency

Contemporary characteristics, outcomes and novel risk score for Takotsubo cardiomyopathy: a national inpatient sample analysis

BackgroundTakotsubo cardiomyopathy (TC) is an established differential diagnosis of myocardial infarction with non-obstructive coronaries with significant interest but limited data on prognostication. We reviewed the characteristics and in-hospital outcomes and...

Outcomes of Single versus Sequential Vein Grafts in Isolated Coronary Artery Bypass Surgery: Insights from a Large Tertiary Care Center

BackgroundSaphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited. MethodsBetween 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency. ResultsAt 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22). ConclusionsShort and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG.