Coronary Artery Bypass Surgery Group Research Articles

PROLIDASE LEVEL IN CORONARY ARTERY DISEASE AND ISCHEMIC MITRAL VALVE INSUFFICIENCY

Plasma prolidase levels change as a determining factor for coronary artery disease and heart valve insufficiency. The aim of this study is to compare plasma prolidase levels in two groups with or without mitral regurgitation who underwent coronary artery bypass surgery (CABS). For this purpose, 45 patients who underwent CABS were included in the study; patients without mitral valve insufficiency who underwent CABS (25 patients) Group 1, patients with mitral valve insufficiency who underwent CABS (20 patients) Group 2. Venous blood was taken from all patients before and after CABS and their prolidase levels were measured. Preoperative and postoperative serum prolidase levels in group 1 were 1038.2 and 1289.43 U/L, respectively. In group 2, preoperative and postoperative serum prolidase levels were 1084.07 and 1337.74 U/L, respectively. A significant difference was found between preoperative and postoperative plasma prolidase levels of Group 1 and Group 2 included in the study (p<0.05). Plasma prolidase level was high in both groups. However, pre- and postoperative serum prolidase levels were found to be higher in patients with mitral valve insufficiency in Group 2. In conclusion, in this study, it was determined that the plasma prolidase level was higher in patients with mitral valve insufficiency who underwent CABS.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians

BackgroundCoronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population. MethodsPatients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010–2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes. ResultsOf ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73–1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78–1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71–1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60–1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74–1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75–1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01–1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16–1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83–0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval –$2,370 to $200). ConclusionOff-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

The Impact of Complete Revascularization in Symptomatic Severe Left Ventricular Dysfunction between Coronary Artery Bypass Graft and Percutaneous Coronary Intervention.

The study aimed to compare the clinical outcomes between the patients receiving coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the patients with symptomatic severe left ventricular (LV) dysfunction and coronary artery disease (CAD). Between February 2007 and February 2020, a total of 745 patients who received coronary artery angiography for reduced LV ejection fraction (LVEF) < 40% and symptomatic New York Heart Association (NYHA) functional class ≥ 3 were recruited. The patients (N = 236) who were diagnosed with dilated cardiomyopathy or valvular heart disease without coronary artery stenosis, those with prior history of CABG or valvular surgery (N = 59), those who presented ST-segment elevated myocardial infarction (STEMI), those with a CAD and SYNTAX score of ≦ 22 (N = 175), those who received emergent CABG for coronary perforation (N = 3), and those who had NYHA class ≦ 2 (N = 65) were excluded. Finally, 116 patients with reduced LVEF and those who had a SYNTAX score >22, who received CABG (N = 47) and PCI (N = 69), were recruited for this study. There was no significant difference in the incidence values of in-hospital course and those of in-hospital mortality, acute kidney injury, and postprocedural hemodialysis. There was no significant difference in the 1-yearfollow-up of recurrent MI, revascularization, or stroke between the groups. The 1-year heart failure (HF) hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (13.2% vs. 33.3%; p = 0.035); however, there was no significant difference in the same variable between the CABG group and the complete revascularization subgroup (13.2% vs. 28.2%; p = 0.160). The revascularization index (RI) was significantly higher in the CABG group than in all patients of the PCI group or complete revascularization subgroup (0.93 ± 0.12 vs. 0.71 ± 0.25; p < 0.001) and (0.93 ± 0.12 vs. 0.86 ± 0.13; p = 0.019). The 3-year HF hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (16.2% vs. 42.2%; p = 0.008); however, there was no difference in the same variable between the CABG group and the complete revascularization subgroup (16.2% vs. 35.1%; p = 0.109). In patients with symptomatic (NYHA class ≥ 3) severe LV dysfunction and CAD, CABG brought less HF admission when compared to patients in the PCI group, but this did not differ when compared to the complete revascularization subgroup. Therefore, an extensive revascularization, achieved by CABG or PCI, is associated with a lower HF hospitalization rate during the 3-yearfollow-up period in such populations.

Long-term results after simultaneous carotid and coronary revascularisation.

The revascularisation strategy for concomitant carotid and coronary disease is unknown. Simultaneous or stage coronary artery stenting and carotid endarterectomy are the most common revascularisation approach in the CABG population. This study aimed to evaluate long-term results after simultaneous carotid artery stenting or carotid endarterectomy in patients who underwent coronary artery bypass surgery. This is a prospective cohort non-randomised single-institution study. During the period from 2012 to 2015, sixty consecutive patients (65.9 ± 7.41 mean) underwent simultaneous carotid artery stenting and coronary artery bypass surgery (n = 30) or simultaneous carotid endarterectomy and coronary artery bypass surgery (n = 30). The primary endpoints were short- and long-term rates of adverse events (transient ischemic attack, stroke, myocardial infarction, and death). The mean follow-up was 62.05 ± 11.12 months. In-hospital mortality was insignificantly higher in the carotid endarterectomy, and coronary artery bypass surgery group (6.6% vs. 0%), the rate of stroke and myocardial infarction was similar (13.3% and 0% in the carotid endarterectomy and coronary artery bypass surgery group vs. 6.6% and 3.3% in the carotid artery stenting and coronary artery bypass surgery group, respectively). The intensive care unit readmission was significantly higher in the surgical revascularisation approach; it was an independent predictor of hospital mortality. The overall mortality during the follow-up period was 14.28% in both groups. Freedom of the composite adverse outcomes (stroke, myocardial infarction, and death) was 78.55%. Comparing two revascularisation strategies is not straightforward due to different anatomical indications for carotid artery stenting and endarterectomy. We consider that each technique has an essential role in carotid revascularisation. Good selection of patients, according to indications, contributes to satisfactory short- and long-term results.

The Effect of Untraditional Lipid Parameters in the Development of Coronary Artery Disease: Atherogenic Index of Plasma, Atherogenic Coefficient and Lipoprotein Combined Index.

ObjectiveIn this study, we investigated the usability of atherogenic indices of patients who underwent coronary artery bypass surgery (CABG) due to coronary artery disease and patients without CAD as risk factors and markers for cardiovascular disease (CVD).MethodsThe data of 150 patients who underwent CABG, and 155 patients who underwent coronary angiography and was not diagnosed with CAD were analysed retrospectively. Demographic data and plasma lipid values were collected. The relationship between these ratios and CVD was investigated via univariate logistic regression analysis performed by creating atherogenic indices.ResultsThe data of 125 patients who underwent CABG between May 2018 and May 2020 (90 males, 35 females; mean age 64,94 ± 9,61), and 155 patients who had coronary angiography between the same dates and found to have no CAD (64 males, 91 females; mean age 60,12 ± 11,6) were analysed retrospectively. The atherogenic index of plasma (AIP), atherogenic coefficient (AC) and lipoprotein combined index (LCI) ratios were found to be significantly higher in the CABG group compared to the control group (p < 0.001). CABG applied patients were divided into three groups according to their SYNTAX Score-I values. There was no statistical difference in the AIP (p = 0.434), AC (p = 0.715) and LCI (p = 0.891) ratios between the groups. In the ROC analysis of the CABG group, it was found that the AC value was the highest in terms of sensitivity with a value of 74.4% (AUC = 0.669, p < 0.001), and the LCI was the highest in terms of specificity with a value of 65.8% (AUC = 0.634, p < 0.001). In the univariate logistic regression analysis created, it was seen that all three indices had a significant effect in the CABG group (AIP; OR 0.493 p = 0,002, AC; OR 0.298 p < 0,001, LCI; OR 0.358 p = 0,001).ConclusionThe use of atherogenic indices in daily practice can be recommended in the process of monitoring the risk of CVD in CAD patients, along with determining those patients’ lipid profiles.

Determinants and Prediction Equations of Six-Minute Walk Test Distance Immediately After Cardiac Surgery.

Background: To date, there is no reference for a 6-min walk test distance (6-MWD) immediately after cardiac surgery. Therefore, this study aimed to identify the determinants and to generate equations for prediction reference for 6-MWD in patients immediately after cardiac surgery.Methods: This is a cross-sectional study of the 6-min walk test (6-MWT) prior to participation in the cardiac rehabilitation (CR) program of patients after coronary artery bypass surgery (CABG) or valve surgery. The 6-MWT were carried out in a gymnasium prior to the CR program immediately after the cardiac surgery. Available demographic and clinical data of patients were analyzed to identify the clinical determinants of 6-MWD.Results: This study obtained and analyzed the data of 1,509 patients after CABG and 632 patients after valve surgery. The 6-MWD of all patients was 321.5 ± 73.2 m (60–577). The distance was longer in the valve surgery group than that of patients in the CABG group (327.75 ± 70.5 vs. 313.59 ± 75.8 m, p < 0.001). The determinants which significantly influence the 6-MWD in the CABG group were age, gender, diabetes, atrial fibrillation, and body height, whereas in the valve surgery group these were age, gender, and atrial fibrillation. The multivariable regression models generated two formulas using the identified clinical determinants for patients after CABG: 6-MWD (meter) = 212.57 + 30.47 (if male gender) − 1.62 (age in year) + 1.09 (body height in cm) − 12.68 (if with diabetes) − 28.36 (if with atrial fibrillation), and for patients after valve surgery with the formula: 6-MWD (meter) = 371.05 + 37.98 (if male gender) − 1.36 (age in years) − 10.61 (if atrial with fibrillation).Conclusion: This study identified several determinants for the 6-MWD and successively generated two reference equations for predicting 6-MWD in patients after CABG and valve surgery.

Minimally Invasive vs Open Coronary Surgery: A Multi-Institutional Analysis of Cost and Outcomes

Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raisedconcern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort. Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis. Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P= .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P= .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P= .013), and had longer intensive care unit (45 vs 30 hours, P= .049) as well as hospital lengths of stay (7 vs 6 days, P= .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG. Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay,and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.

Abstract 225: Impact of Revascularization Strategy on Risk of Readmission After Non-ST Elevation Myocardial Infarction

Background: It is unclear how revascularization strategy (medical management vs percutaneous coronary intervention vs coronary artery bypass surgery), affects 90-day readmissions after Non-ST Elevation Myocardial Infarction (NSTEMI). Methods: We identified cases of NSTEMI at a single quaternary care medical center between January 1 st , 2010 to January 1 st , 2017 and readmissions within 90 days. Cases were categorized based on revascularization strategy into medical management, PCI (percutaneous coronary intervention) or CABG (coronary artery bypass surgery). The readmissions were categorized according to the time of readmission into early (0-30 days) and late (31-90 days) after discharge. The instantaneous risk of readmission following each treatment option was calculated using the parametric method. Results: We identified 6626 patients with index MI, of which 4692 patients had NSTEMI. There were a total of 2051 readmissions within 90 days. The risk of readmission for CABG and PCI treatment groups yielded an early peaking phase followed by a constant risk whereas the risk of readmission in the medically managed group showed an early decreasing phase followed by a constant risk. An unadjusted comparison of the risk of readmission between the three groups showed that the PCI group had the lowest early risk of readmission (P=0.03). The medically managed group had the highest risk of readmission. Conclusion: Patients with NSTEMI who are medically managed appear to be at higher risk for readmission than revascularized patients. Understanding the care processes for these patients may serve as a future opportunity to improve outcomes in these high-risk patients.

Early Referral to Coronary Artery Bypass Grafting Following Acute Coronary Syndrome, Trends and Outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010

Limited information exists on whether changes in medical practices over the study decades have affected the outcomes of acute coronary syndrome (ACS) patients who undergo early coronary artery bypass surgery (CABG) during index hospitalisation. Data on trends for early CABG referral and associated outcomes were obtained among 11,485 ACS patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) 2000-2010. Among 11,485 patients, 566 (5%) were referred to early CABG. These patients displayed higher risk characteristics, including Killip class >II, anterior myocardial infarction, greater left ventricular dysfunction, and more frequent use of mechanical ventilation and intra-aortic balloon pump (all p<0.01). Nevertheless, mortality rates of patients referred to early CABG vs. treated with percutaneous coronary intervention (PCI) or medically, was similar (11.4% vs. 10.2%; log-rank p-value=0.40). There was a significant decline in the referral trend over the study decade (6.7% - 1.7%; p<0.001). One year survival was similar between patients referred to early CABG during the late (years: 2006-2010) vs. early (years: 2000-2005) period (85.7% vs. 90%; log-rank p-value=0.15), whereas, among patients who didn't undergo early CABG, and underwent percutaneous coronary intervention (PCI) or medical management only, enrolment during the late periods was associated with a significant survival benefit (91.5% vs. 88.1%; log-rank p-value<0.001). Over the study decade there was a significant decline in referral for early CABG, without a difference in the one-year mortality between the early and non-early CABG group.

Coronary artery bypass surgery compared with percutaneous coronary interventions in patients with insulin-treated type 2 diabetes mellitus: a systematic review and meta-analysis of 6 randomized controlled trials.

BackgroundData regarding the long-term clinical outcomes in patients with insulin-treated type 2 diabetes mellitus (ITDM) revascularized by either coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) are still controversial. We sought to compare the long-term (≥1 year) adverse clinical outcomes in patients with ITDM who underwent revascularization by either CABG or PCI.MethodsRandomized Controlled Trials (RCTs) comparing the long-term clinical outcomes in patients with ITDM and non-ITDM revascularized by either CABG or PCI were searched from electronic databases. Data for patients with ITDM were carefully retrieved. Odd Ratio (OR) with 95 % confidence interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.ResultsSix RCTs involving 10 studies, with a total of 1297 patients with ITDM were analyzed (639 patients from the CABG group and 658 patients from the PCI group). CABG was associated with a significantly lower mortality rate compared to PCI with OR: 0.59, 95 % CI 0.42–0.85; P = 0.004. Major adverse cardiovascular and cerebrovascular events as well as repeated revascularization were also significantly lower in the CABG group with OR: 0.51, 95 % CI 0.27–0.99; P = 0.03 and OR 0.34, 95 % CI 0.24–0.49; P < 0.00001 respectively. However, compared to PCI, the rate of stroke was higher in the CABG group with OR: 1.41, 95 % CI 0.64–3.09; P = 0.40, but this result was not statistically significant.ConclusionCABG was associated with significantly lower long-term adverse clinical outcomes compared to PCI in patients with ITDM. However, due to an insignificantly higher rate of stroke in the CABG group, further researches with a larger number of randomized patients are required to completely solve this issue.

The year in cardiology 2015: coronary intervention.

The field of percutaneous coronary intervention (PCI) remains extremely active, with major advances involving revascularisation strategies and techniques, adjuvant antithrombotic therapy (with a particular emphasis this year on the optimal duration of antiplatelet therapy after drug-eluting stent (DES) stenting), concerns regarding the importance and risks of bleeding and methods to decrease those risks and a strong focus on the study of newer generation DES and bioresorbable devices with lingering concerns regarding the safety of the latter. ### Myocardial revascularization Given the improved clinical outcomes of newer generation DES, comparisons between these and coronary artery bypass surgery (CABG) are important. The BEST trial1 randomly assigned 880 patients with multivessel disease to either PCI with everolimus-eluting stents (EES) or to CABG. After a median follow-up of 4.6 years, major adverse cardiac events were higher in the PCI group than in the CABG group (15.3 vs. 10.6%, P = 0.04), driven by a reduction of repeat revascularization but also spontaneous myocardial infarction (MI) in the surgical group, reaffirming the role of CABG surgery in the management of patients with multivessel disease in the era of newer DESs. The management of in-stent restenosis can be difficult. The PROSPERO network meta-analysis of 27 trials2 attempted to synthesize the evidence and suggested that PCI with EES yielded the best angiographic and clinical outcomes and that drug-coated balloons provided favourable angiographic results without adding an additional metal layer. The RIBS-IV trial3 compared prospectively these two strategies in 309 patients with in-stent restenosis after DESs and found that EES provided superior 1-year clinical (lower composite of cardiac death, MI, and target vessel revascularization, 10 vs. 18%, P = 0.04) and angiographic outcomes compared …

Adverse events following percutaneous and surgical coronary revascularisation: Analysis of non-MACE outcomes in the Stent or Surgery (SoS) Trial

ObjectivesTo analyse adverse events requiring or prolonging hospitalisation in the Stent or Surgery (SoS) trial. BackgroundMany adverse events following coronary revascularisation are non-major adverse cardiovascular events (non-MACE). Trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) have reported rates of mortality and MACE only. Material and methodsComparisons between PCI and CABG groups in the SOS trial were by intention to treat. For patients with non-fatal/non-MACE, number of events per 100 patient years follow-up and duration of hospital stay were assessed. Competing risk analysis was used to illustrate temporal pattern of adverse outcomes. ResultsDuring 2y median follow up, 1 one or more adverse event occurred in 47.3% (231) of the PCI group and 53% (265) of the CABG group (p=0.086). Non-fatal/non-MACE occurred in 11.9% of the PCI group and 38.6% of the CABG group (p<0.001). Non-fatal/non-MACE per 100 patient years follow-up was 17.49 (PCI) and 35.04 (CABG), rate ratio 2.0, 95% CI 1.7 to 2.4, p<0.001. Cumulative non-fatal/non-MACE associated hospital stays were 1387 and 3287days in PCI and CABG groups respectively. Median duration of hospitalisation per non-fatal/non-MACE was 5days (interquartile range 2 to 11.75days) in the PCI group and 6days (interquartile range 2 to 12days) in the CABG group, p=0.245. ConclusionsCABG had lower cumulative incidence of fatal or MACE outcomes, higher cumulative incidence of non-fatal/non-MACE outcomes, and longer cumulative hospitalisation periods compared to the PCI group.

Abstract 122: Characteristics of Patients with Multivessel Coronary Disease Treated with Percutaneous Intervention Versus Bypass Surgery and Preliminary Mortality Outcomes: A Province-wide Field Evaluation

Introduction: Wide variation in choice of revascularization treatment for patients with multivessel coronary disease has been observed and outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) are increasingly examined. Our publicly funded cardiology evaluation unit was mandated by the Quebec Ministry of Health to evaluate the practice of multivessel revascularization and its outcomes across Quebec’s 8 tertiary cardiac centers offering both PCI and CABG. Methods: Hospital records were used to identify all multivessel (≥2 myocardial territories) interventions by PCI and isolated CABG in each center in 2010-12. Primary PCI patients were excluded. A maximum of 300 patients treated with CABG and 300 patients treated with PCI in each center were randomly selected for chart review by our evaluation unit. Results: The study cohort included 2018 PCI patients and 2274 isolated CABG patients. Median age was 66 years for both PCI (interquartile range, IQR: 59-76) and CABG (IQR: 59-72) and prevalence of most risk factors and comorbidities was very similar. However, compared to CABG patients, there were more females in the PCI group (27% vs 17%), more cardiogenic shock (2.2% vs 0.6%), more patients with previous PCI (27% vs 16%) and previous valve surgery (1.2% vs 0.1%), and more patients with interventions in only 2 myocardial territories (89% vs 31%). The PCI group was more likely than the CABG group to have acute myocardial infarction (AMI) (32% vs 18%) but less likely to have heart failure on admission (9% vs 18%). Almost 1 in 5 (19%) PCI patients were treated for left main disease. Diabetes was present in 29% of PCI patients vs 37% of CABG patients. Compared to CABG, PCI patients had a shorter median delay between admission and intervention (0 vs 2 days) as well as between intervention and discharge (1 vs 6 days) and were more likely to be transferred out to another hospital (37% vs 14%). However, mortality before discharge or transfer from tertiary cardiac centers was higher for PCI than CABG patients both with AMI (3.1% vs 0.7%) and without AMI (1.0% vs 0.5%). The differences of all reported comparisons were statistically significant (p&lt; 0.001) except for in-hospital mortality without AMI (p=0.25). Conclusions: Patients with multivessel disease who were treated with PCI were more likely to present with acute symptoms, have more cardiogenic shock and more previous valve surgery but have less extensive coronary disease, less diabetes and less heart failure. Age and other risk factors and comorbidities were very similar in the 2 groups. Crude mortality during the index surgical hospital admission was higher for PCI despite a shorter length of stay. To gain more insight into these results, it will be important to link to medico-administrative data to examine 30-day and 1-year mortality and to adjust appropriately for potential confounders.

Comparison of survival rate between coronary artery bypass surgery and angioplasty based on number of diseased coronary vessels

This study has been conducted to compare one-year survival rate of patients who underwent coronary artery bypass sur- gery (CABG) vs. percutaneous coronary intervention (PCI) in general as well as considering the number of diseased coro- nary vessels. In this retrospective study, we reviewed the medical records of patients who underwent CABG (484 cases) or PCI (292 cases) at out university heart center from 2009 to 2012. The mortality and survival was compared between the two studied groups based on left ventricular function and number of diseased coronary vessels. Twenty-seven patients (5.57%) died in CABG group which was significantly higher than in PCI group (8 cases, 2.73%); P= 0.04. However, no significant dif- ference was observed regarding mortality between CABG and PCI groups in one- diseased vessel (5.15% vs. 2.22%, P= 0.28), two- diseased vessel (6.12% vs. 3.57%, P= 0.41), and three-vessel disease (5.41% vs.0, P= 0.4). Although PCI was associated with a better one-year survival rate compared to CABG, but number of the diseased coronary vessels did not af- fect survival rate significantly.

Abstract 19155: The Impact of Expeditious Management of Perioperative Myocardial Ischemia in Patients Undergoing Isolated Coronary Artery Bypass Surgery

Objective: To analyze the effect of immediate treatment of perioperative myocardial ischemia due to early graft failure in patients undergoing coronary artery bypass surgery (CABG). Patients and methods: Between January 2004 and December 2010, 7489 patients underwent isolated CABG at our institution. All patients (n=427, 5.7%) who showed evidence of perioperative myocardial ischemia (PMI) underwent emergent coronary angiography. PMI was characterized by an isoenzyme ratio of creatinine phosphokinase (CK/CK-MB) &gt; 10% and/or new ST-segment changes and/or recurrent episodes of ventricular tachycardia or fibrillation and/or hemodynamic deterioration with new regional wall motion abnormalities on echocardiography. One thousand and thirteen grafts and 1131 distal anastomoses were examined angiographically. Results: One hundred and seventy-six patients had a normal postoperative coronary angiography. Two hundred and fifty-one patients had stenoses or occlusions of 372 grafts. Revision CABG (group A) or percutaneous coronary intervention (PCI) (group B) was performed in 130 (51.8%) and 31 (12.4%) patients with graft stenosis or occlusion, respectively. Conservative therapy was implemented in 92 (36.6%) patients (group C). In-hospital mortality was 8.4% and 2.9% in patients with and without PMI (p &lt; 0.001). In the former group, in-hospital mortality was 10.4% and 5.7% in patients with and without graft failure, respectively (p=0.087). There was no difference in early and long-term survival between the 3 treatment groups for graft failure (p=0.8). On the other hand, 1- and 5-year survival in patients with no PMI (93.3±0.03% and 83.6±0.05%, respectively) was significantly better than those with PMI (92.3±0.1% and 82.4±0.2%, respectively) [p&lt;0.001 log rank]. When in-hospital mortality was excluded, there was no difference (p=0.1) in long-term survival between patients with and without perioperative myocardial ischemia. Conclusions: Perioperative ischemia is associated with increased in-hospital mortality in patients undergoing isolated coronary bypass surgery. Expeditious treatment of bypass graft stenosis or occlusion results in similar long-term survival to non-ischemic patients in hospital survivors.

Clopidogrel Within Few Hours of Coronary Artery Bypass Grafting Does Significantly Increase the Risk of Bleeding.

BackgroundPostoperative bleeding after coronary artery surgery is partly related to platelet dysfunction. The aim of this study was to evaluate the effects of a single loading dose of clopidogrel (300 mg) before coronary angiography on bleeding and use of blood and blood products after emergency coronary artery bypass surgery (CABG).MethodsThis is a nonrandomized observational prospective study between January, 2006 till December 2009, at a university hospital, we compare the results of a cohort of 65 patients who received 300 mg clopidogrel during coronary angiography that was followed by emergency CABG (group A or study group) to a cohort of 206 patients who underwent elective coronary artery bypass surgery during the same period by the same surgeons in whom clopidogrel was stopped 7 days before surgery (Group B or control group). Emergency surgery was done because of critical coronary anatomy or because of ongoing chest pain. All patients in the two groups were kept on 100 mg of aspirin until the day of surgery. Outcome data used to compare the two groups, Chest tube drainage in first 12 hours (12 h), need for re-exploration and use of blood and blood product transfusion were prospectively collected.ResultsPostoperative bleeding, reoperation rates for bleeding and use of blood products are significantly more in those who received a loading dose of clopedogril within few hours of CABG (group A) compared to those who stopped clopedogril for a week before CABG.ConclusionsPreoperative 300 mg of clopidogrel is associated with significant increase in post operative bleeding, need for surgical exploration and use of blood and blood product transfusion after CABG.

Coronary Artery Bypass Surgery Is Superior to Percutaneous Coronary Intervention With Drug-Eluting Stents for Patients With Chronic Renal Failure on Hemodialysis

Improvements in the results of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have been extending their use in patients with all forms of coronary artery disease. The purpose of this study was to compare the midterm clinical results of coronary artery bypass surgery (CABG) and PCI with DES in patients with chronic renal failure on hemodialysis. From January 2002 to December 2006, 29 patients underwent CABG, and 75 patients underwent PCI with DES. For CABG, 24 patients had off-pump surgery. The mean follow-up was 32.0 +/- 22.0 months for CABG and 23.5 +/- 14.8 months for PCI. Survival, cardiac death, major adverse cardiac events (cardiac death, myocardial infarction, revascularization), and target lesion revascularization were analyzed using the Kaplan-Meier method. Preoperative characteristics and risk factors were compatible between the groups except for the European System for Cardiac Operative Risk Evaluation (7.3 +/- 2.7 for CABG and 5.0 +/- 2.4 for PCI, p < 0.0001) and the presence of a left main trunk lesion (53.3% for CABG and 18.7% for PCI). Thirty-day mortality was 3.3% for CABG and 4.0% for PCI. The 2-year survival rate was 84.0% for CABG and 67.6% for PCI (p = 0.0271). The cardiac death-free curve at 2 years was 100% for CABG and 84.1% for PCI (p = 0.0122). The major adverse cardiac events-free rate at 2 years was 75.8% for CABG and 31.5% for PCI (p < 0.0001). During the follow-up period, there were 6 late deaths in the CABG group and 27 late deaths (including 6 sudden deaths) in the PCI group. Coronary artery bypass grafting was superior to PCI with DES in patients with chronic renal failure on hemodialysis in terms of long-term outcomes for cardiac death, major adverse cardiac events, and target lesion revascularization. The DES carried a higher risk for sudden death, which might be associated with stent thrombosis.

Late outcomes of on-pump and off-pump redo coronary artery bypass grafting

Benefits of off-pump surgery are still widely debated in the literature comparing with conventional coronary artery bypass grafting. The aim of our study was to compare the late outcomes of patients who underwent on-pump redo coronary artery bypass surgery with those who had off-pump redo coronary artery bypass surgery. Two groups of patients were compared. Group 1 consisted of 34 patients who underwent off-pump redo coronary artery bypass surgery, and Group 2 included 160 patients who underwent on-pump redo coronary artery bypass surgery. Both groups of patients were operated on by the same team of surgeons at the same time period. Groups did not differ by age, gender, functional class, preoperative myocardial infarction rate, and left ventricular function. More patients with hypertension were in the off-pump group. Significantly more grafts were performed in the on-pump group. Survival, presence of angina, reoccurrence of postoperative myocardial infarction, necessity of percutaneous transluminal coronary angioplasty and reoperations were evaluated in late follow-up period. The duration of follow-up was 3.37+/-2.15 years in the off-pump group and 3.27+/-2.36 years in the on-pump group. Survival after 6 years in the off-pump and on-pump redo coronary artery bypass surgery groups was 85.3% and 83.6%, respectively (P=0.758). Five years after redo operation, 54.9% of patients who underwent off-pump coronary artery bypass surgery and 69.3% of patients who underwent on-pump coronary artery bypass surgery had no angina (P=0.174). There were no major cardiac events (percutaneous transluminal coronary angioplasty, death, myocardial infarction, and reoperations) after 6 years in 69.7% of patients in the off-pump group and 76.9% of patients in the on-pump group (P=0.343). Five years after redo surgery, 79.4% of patients in the off-pump group and 91.9% in the on-pump group were free of percutaneous transluminal coronary angioplasty (P<0.02). There was no difference in survival despite the fact that patients in the on-pump group received more grafts than those in the off-pump group. Recurrence of angina and incidence of major cardiac events were almost equal in both the groups. Percutaneous transluminal coronary angioplasty was more frequently performed in the patients of off-pump group at late follow-up.

Coronary Artery Bypass Surgery Versus Percutaneous Coronary Artery Intervention in Patients on Chronic Hemodialysis: Does a Drug-Eluting Stent Have an Impact on Clinical Outcome?

Coronary revascularization methods continue to be refined, and the emergence of the drug-eluting stent (DES) has especially changed clinical practice related to ischemic heart disease. For chronic hemodialysis (HD) patients, however, the impact of DES on clinical outcome is yet to be determined. Forty-six consecutive chronic HD patients who underwent myocardial revascularization in our institute were retrospectively reviewed. Twenty-eight patients underwent coronary artery bypass surgery (CABG) and 18 patients underwent percutaneous coronary artery intervention (PCI). Patient characteristics were similar between the two groups. In the CABG group, bilateral internal thoracic artery (ITA) bypass grafting was performed in 27 patients and off-pump CABG was performed in 20 patients. In the PCI group, a DES was used in 12 patients. The number of coronary vessels treated per patient was higher in the CABG group (CABG: 4.25 +/- 1.32 vs. PCI: 1.44 +/- 0.78; p < 0.001). Two-year survival rates were similar between the two groups (CABG: 94.1% vs. PCI: 73.9%; p = 0.41), but major adverse cardiac event-free survival (CABG: 85.9% vs. PCI: 37.1%; p = 0.001) and angina-free survival (CABG: 84.9% vs. PCI: 28.9%; p < 0.001) rates were significantly higher in the CABG group. The one-year patency rate for the CABG grafts was 93.3% (left ITA: 100%, right ITA: 84.6%, sapenous vein: 90.9%, gastro-epiploic artery: 100%), and six-month restenosis rate for PCI was 57.1% (balloon angio-plasty: 75%, bare metal stent 40%, DES: 58.3%). Even in the era of DES, clinical results favored CABG. The difference in clinical results is due to the sustainability of successful revascularization.

Abstract 3241: Long-TermSurvival after Coronary Artery Bypass versus Percutaneous Coronary Intervention with Bare Metal Stent Implantation in Patients with Diabetic Retinopathy

Background : Coronary heart disease is the leading cause of death in diabetic population. Compared with diabetics without retinopathy, diabetics with retinopathy have an increased risk of myocardial infarction and death from coronary heart disease. Therefore, it is crucial to select an appropriate revascularization method in this considerable high-risk group. Methods: Between 1996 and 2004, a total of 149 patients with diabetic retinopathy underwent revascularization, either coronary artery bypass surgery (CABG) (n=56) or percutaneous coronary intervention with bare metal stents (BMS) (n=94). We compared overall survival rates of the two methods. Mortality was estimated according to Kaplan-Meier methods and was compared using the log-rank test. Results: The average follow-up from the time of the initial revascularization was 59.7 ± 33.3 months. During the entire follow-up, there was 8(14.5%)death in the CABG group and 27(28.7%) deaths in the BMS group. The average duration between death and revascularization was 81.3 ± 24.6 for the CABG group and 29.9 ± 23.8 for the BMS group (P&lt;0.001). The 6-year overall survival was 94.8% for the CABG group and 73.6% for the BMS group. Mortality curves differed significantly between the two groups (P=0.004) (Figure ). After adjustment for baseline characteristics including age, sex, HbA1c, insulin, serum creatinine, ejection fraction, and the extent of coronary disease, the hazard ratio of death afforded by CABG was 0.36 (95% confidence interval, 0.15–0.87; P=0.023). Conclusions: In patients with diabetic retinopathy, CABG conferred survival benefit over BMS implantation.