Coronary Bypass Grafting Research Articles

Long-term outcomes of complete bilateral internal thoracic artery grafting and traditional coronary bypass surgery in patients with multivessel coronary artery disease

Aim. To evaluate the long-term results of complete bilateral internal thoracic artery (BITA) grafting and traditional coronary bypass grafting (CABG) in patients with multivessel CAD.Material and methods. From June 2018 to December 2021, 646 CABG operations were performed in patients with multivessel CAD at the Federal Center for Cardiovascular Surgery (Krasnoyarsk). There were 178 patients receiving BITA grafting and 468 — traditional revascularization technique. After propensity score matching, 356 patients were selected, of which 99 had on-pump BITA (group 1), 178 — on-pump traditional revascularization (group 2), and 79 — off-pump BITA (group 3). There were more males (p=0,143 and p=0,547). The groups were comparable in age (p=0,343 and p=0,104), body mass index (p=0,532 and p=0,759), diabetes (p= 0,705 and p=0,667), the number of hemodynamically significant coronary stenoses (p=0,370 and p=0,595).Results. The follow-up period lasted 32,8±8,52 months. Long-term patient survival was 83,9% in group 2,93% in group 1 (p=0,041) and 94% in group 3 (p=0,039). Freedom from cardiovascular mortality was 100% in both groups of BITA grafting and 92,5% in group 2 (p=0,001 and p=0,039), freedom from major cardiovascular events was 94,2% in group 1, 85,1% in group 2 and 98,5% in group 3 (p=0,032 and p=0,03).Conclusion. BITA grafting is a modern effective and safe method of surgical myocardial revascularization both on- and off-pump. Up to 33 months. BITA grafting was associated with significantly better patient survival, complete freedom from cardiovascular mortality and a lower incidence of major cardiovascular events.

The Feasibility of Less-Invasive Bentall Surgery: A Real-World Analysis.

Minimally invasive approaches are being used increasingly in cardiac surgery and applied in a wider range of operations, including complex aortic procedures. The aim of this study was to examine the safety and feasibility of a partial upper sternotomy approach for isolated elective aortic root replacement (a modified Bentall procedure). We performed a retrospective analysis of 768 consecutive patients who had undergone isolated Bentall surgery between January 2000 and January 2021 at our institution, with the exclusion of re-operations, endocarditis, acute aortic dissections, and root replacement with major concomitant procedures such as multi-valve or coronary bypass surgery. A total of 98 patients were operated on via partial sternotomy (PS) and were matched 2:1 to 196 patients operated on via full sternotomy (FS). The procedure time was 12 min longer in the PS group (205 min vs. 192.5 min in the FS group, p = 0.002), however, cardiopulmonary bypass and aortic cross-clamp times were comparable between groups. Eight PS-procedures were converted to full sternotomy, predominantly for bleeding complications (n = 6). Re-exploration for acute bleeding was necessary in 11% of the PS group and 4.1% of the FS group (p = 0.02). Five FS patients and none in the PS group required emergency coronary bypass grafting for postoperative coronary obstruction (p = 0.2). PS patients were hospitalized for a significantly shorter period (9.5 days vs. 10.5 days in the FS group, respectively). There were no significant differences regarding in-hospital (p = 0.4) and mid-term mortality (p = 0.73), as well as for other perioperative complications. Performing Bentall operations via partial upper sternotomy is associated with similar perfusion and cross-clamp times, as well as overall mortality, when compared to a full sternotomy approach. A low threshold for conversion to full sternotomy should be accepted if limited access proves insufficient for the handling of intraoperative complications, particularly bleeding.

Single-Centre Registry Analysis of Patients Who Underwent Percutaneous Coronary Intervention on Their Coronary Bypass Grafts

BackgroundThe study assessed the outcomes of patients undergoing percutaneous coronary intervention (PCI) to bypass grafts, focusing on all-cause mortality and target vessel failure (TVF) rates. MethodsA single-centre registry analysis included 364 patients who underwent PCI on coronary bypass grafts between 2008 and 2019. The study analyzed all-cause mortality and TVF, which encompassed target lesion revascularization, target vessel revascularization, and medically treated occluded target graft post-PCI. ResultsThe median age of the patients was 71 years (interquartile range: [IQR] 65-78), with 82.1% being male. Most patients (94.8%) received PCI on saphenous vein grafts, and the median graft age was 13.0 years (IQR: 8.4-17.6). Drug-eluting stents were used more frequently (54.4%) than bare-metal stents (45.6%), with a median stent diameter of 3.5 mm (IQR: 3-4) and length of 19 mm (IQR: 18-28). Outcome differences were not significant for PCI sites (aorto-ostial, graft body, anastomosis), use of drug-eluting stents, or use of protection devices. The 1-year mortality rate was 3.3%, whereas the combined rate of TVF or death was 20.3%. After 5 years, the mortality rate increased to 14.9%, and the combined TVF or death rate rose to 40.3%. Multivariable analyses revealed that chronic kidney disease was independently associated with mortality (hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.16-2.61, P = 0.007), whereas hypertension (HR 2.42, 95% CI 1.32-4.42, P = 0.004) and increased stent length (HR 1.01, 95% CI 1.00-1.02, P = 0.007) were independently associated with the TVF-or-mortality outcome. ConclusionsPatients undergoing PCI to bypass grafts experience considerable adverse outcomes over a 5-year period, highlighting the need for further strategies in managing this high-risk population.

Angiographic definition, incidence, predictors and clinical impact of early coronary graft failure in patients undergoing coronary artery bypass graft surgery

Abstract Introduction Coronary graft failure (CGF) may occur early after coronary bypass graft surgery (CABG), potentially leading to adverse clinical outcomes. However, data regarding incidence, diagnostic strategies and identification of individuals at risk of developing early CGF are scarce. Purpose The aim of this study was to establish a definition of early CGF based on invasive coronary angiography (CAG), to identify clinical and perioperative risk factors of early CGF and to define the clinical impact of early CGF in terms of major adverse cardiovascular events (MACE: death, myocardial infarction and revascularisation) at 5-years follow-up. Methods This retrospective observational study included CABG patients who underwent CAG prior to post-surgery discharge between 2012-2022 in a tertiary center. The decision to perform a CAG was based on clincal criteria indicative of myocardial ischemia. All CAGs were reviewed by two interventional cardiologist and a thoracic surgeon. Early CGF was defined as a dysfunctional coronary graft resulting from any of the following angiographic findings: stenosis of proximal or distal anastomosis, stenosis of the bypass conduit, bypass occlusion, reduced bypass flow (TIMI<1) and kinking/tenting/dissection of the bypass leading to lumen reduction. Clinical data and ECG recordings during hospitalization were collected. Comparisons between patients with vs. without early CGF were performed. Kaplan-Meier analysis was performed to estimate cumulative survival free of MACE at 5-years follow-up. Multivariate analysis was performed to identify predictors of early CGF. Results A total of 92 patients (79% male, 66.1±10 years-old) were included. CGF was present in 55 patients (60%). Compared to the patients without graft failure (n=37 (40%), there were no differences in baseline demographics and intra- and postoperative technical and clinical parameters. At 5-years follow-up, MACE was observed in 57 patients (18 death, 34 myocardial infarction, 42 revascularization). There were 50 revascularization procedures performed in 42 patients (46%). Of them, 35 (83%) were performed in patients with early CGF vs. 7 (17%) in patients without CGF (p<0.001). Patients with early CGF showed a significantly lower MACE-free five-year survival rate (p<0.001) (Figure) 1). On multivariate analysis, venous grafts (p=0.006), Y-graft configuration (p<0.001) and the need of inotropic agents for hemodynamic support (p=0.029) showed a significant association with early CGF. Conclusion In CABG patients undergoing clinically indicated CAG prior to discharge, early CGF was observed in 60%. Most patients underwent new revascularisation. Patients with early CGF showed a higher rate of MACE at 5-years follow-up, emphasizing the necessity to recognize and treat CGF. Venous grafts, Y-graft configuration and the need of inotropic agents for hemodynamic support 12h postoperatively were associated with early CGF.

Feasibility and accuracy of real-time 3D-holographic graft length measurement, a sub-study of the FAST-TRACK CABG trial

Abstract Background 3D Hologram is an emerging tool for intuitively manipulating and visualizing CT images. Mixed reality (MR) technology can display high-definition 3D holograms while preserving situational awareness. The new MR software offers the possibility to measure 3D objects using hand gestures and voice commands. However, these measurements made on 3D holograms have not been validated. Purpose We aimed to assess the feasibility and accuracy of using CT-derived 3D holograms for bypass graft length measurement. Methods Twenty-seven consecutive cases in the FAST TRACK CABG trial were included. The post-operative CT images performed at 30 days follow-up were analyzed in an independent core lab. Two analysts blinded to clinical information performed Holographic reconstruction and measurement using the CanaLife Holo software (Medapp, Krakow, Poland). (Figure 1) Inter-observer agreement was assessed in the first 20 cases. Another analyst with full access to clinical information performed the validation measurements on the CardIQ W8 system (GE Healthcare, Milwaukee, Wisconsin). (Figure 1) Results A total of 62 grafts (27 left internal mammary artery grafts, 27 saphenous vein grafts, and 8 right internal mammary artery grafts) were measured. There was an excellent inter-observer agreement between the analysts in the first 47 grafts analyzed (interclass correlation 0.9879 [0.9783-0.9933]). (Figure 2A, 2B) On average, holographic reconstruction and measurement of a case took 3 minutes and 36 seconds± 50.74 seconds compared to around 10 minutes per vessel on the traditional CT system. There was no significant difference between the graft length measured by hologram and CT (188.59±51.63 mm vs. 183.95±50.93 mm, p=0.616). The length measured by hologram and CT were similar across different graft types. The measurements of hologram and CT are highly correlated (r=0.973, p <0.001) with an excellent agreement (interclass correlation 0.9928 [0.9880-0.9957]). (Figure2C, 2D) Conclusion Holographic vessel length measurement is feasible, fast, and accurate even for tortuous coronary bypass grafts. This new methodology can empower surgeons to visualize and measure the results of their work by themselves and may provide insights for procedure evaluation. 3D Holograms can eventually empower surgeons to plan the precise length of the arterial and venous grafts to be harvested for every individual case.

Differential effects of heart failure with reduced ejection fraction on locomotor and respiratory muscles

Abstract Background Muscle weakness impairs quality-of-life, exercise capacity, and survival in patients with heart failure and reduced left ventricular ejection fraction (HFrEF). However, the effects on systemic concentrations and local expression of inflammatory cytokines and myokines as well as metabolic markers might differ between locomotor and respiratory muscles. Purpose We prospectively evaluated clinical, functional, and molecular alterations of the diaphragm and the M. vastus lateralis (MVL) from HFrEF patients receiving a left ventricular assist device compared to patients without heart failure undergoing elective coronary bypass grafting (control). Methods Participants (Controls=21, HFrEF=18) underwent cardiopulmonary exercise and respiratory and leg muscle testing. Serum concentrations and local expression of inflammatory cytokines and myokines as well as key enzymes of metabolic pathways were examined in biopsies of the diaphragm and MVL. Results Exercise capacity, respiratory muscle function and endurance force of locomotor muscles were significantly reduced in HFrEF compared with controls (all p<0.05). The serum concentration of Il-6, Il-1beta and TNF-alpha were significantly higher or solely detectable in HFrEF compared with controls. Local mRNA expression of Il-6 was not different in MVL but 2.2-fold higher in the diaphragm of HFrEF compared with controls (p=0.013). In contrast, mRNA expression of Il-6 receptor was significantly reduced by 38% (p=0.004) in MVL of HFrEF compared with controls but comparable in the diaphragm. Serum concentrations of FGF-21 and Musclin were significantly higher in HFrEF compared with controls (all p<0.05). Local mRNA expression of FGF-21 was significantly lower in both MVL and diaphragm of HFrEF compared with controls. FGF-21 receptor 1 mRNA expression was reduced by 18% in the MVL of HFrEF (p=0.02), whereas co-receptor klotho was comparable to controls. In the diaphragm, FGF-21 receptor 1 mRNA expression was comparable between HFrEF and controls, but the co-receptor klotho had a 5-fold higher mRNA expression in HFrEF (p=0.002). We examined the activity of key enzymes of glucose, lipid and ketone metabolism as well as key enzymes of the Krebs cycle. The main differences were found for ß-hydroxyacyl-CoA Dehydrogenase in the diaphragm with a 1.6-fold higher activity in HFrEF compared with controls (p=0.01) and for succinyl-CoA: 3-ketoacid-coenzyme A transferase in the MVL with a 2-fold higher activity in HFrEF compared with controls (p<0.01) indicating a main utilization of lipids in the diaphragm and of ketones in the MVL for energy supply. Conclusions HFrEF induced divergent effects on inflammatory markers, myokine expression and metabolic parameters in locomotor and respiratory muscles in HFrEF patients compared with controls. This indicates that different molecular alterations contribute to locomotor/respiratory muscle dysfunction and reduced whole-body exercise capacity.

Biomarker-based clinical subphenotypes of cardiac surgery associated acute kidney injury and their association with in-hospital treatments and outcomes: a data-driven cluster analysis

Abstract Background Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a prevalent and detrimental complication after cardiac surgery. Its etiology, pathophysiology, and clinical features are often obscure and heterogenous, with varying prognosis and therapeutic requirements. Cluster analysis has been increasingly used to profile complex diseases, but no prior studies have applied it to the CSA-AKI population. Purpose We aim to employ an unsupervised, data-driven cluster analysis approach utilizing routinely available and previously reported perioperative biomarkers to identify CSA-AKI subphenotypes that exhibit varying treatment requirements and in-hospital outcomes. Methods Patients diagnosed with CSA-AKI in accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, who underwent coronary bypass grafting surgery in a single institution and had comprehensive perioperative data, were included (n=7 796). Cluster analysis based on 12 routinely available perioperative biomarkers was performed to partition CSA-AKI subphenotypes. Treatment requirements for vasoactive supports, diuretics, and dialysis, as well as AKI duration and in-hospital mortality rates, were compared among the identified subphenotypes. Results Three distinct clusters of patients with CSA-AKI were identified with different clinical characteristics, treatment needs, and in-hospital outcomes. Cluster 1(n=2 452, 31.5%) was characterized by normal NT-proBNP level, less comorbidities, predominantly isolated surgery, and better prognosis. Cluster 3 (n=1 060, 13.6%) was distinguished by extremely inflammatory states (significantly higher hsCRP level), more comorbidities, more complex surgery, and worse prognosis. Cluster 2 (n=4 284, 55.0%) was considered the intermediate cluster. CSA-AKI patients in cluster 3 exhibited significantly higher in-hospital mortality rate, longer AKI duration and hospital stay, and increased requirements for vasoactive supports, diuretics, and dialysis compared with the other two clusters. Notably, according to the current KDIGO criteria, 87.4% of cluster 3 patients are classified as only stage 1. Conclusions Three clinical subphenotypes of CSA-AKI were identified based on routine perioperative biomarkers, which demonstrated varying treatment requirements and in-hospital outcomes. This cluster analysis augments the current severity-based staging system for general AKI, providing additional risk stratification and treatment implications that are more tailored to cardiac surgery patients.

Abstract 11840: Outcomes and Disparities of Asian Patients With Severe Chronic Kidney Disease Admitted for Heart Failure

Introduction: Socioeconomic disparities in cardiovascular and renal disease pose global public health challenges Despite its large population, Asia lacks proportional representation in heart failure (HF) data, limiting our understanding of risk factors and outcomes for Asians with HF and severe CKD. This study aims to explore the sex, racial, and ethnic differences in in-hospital all-cause mortality, baseline risk factors, and in-hospital complications among Asian patients admitted for HF with CKD. Hypothesis: Asian patients with CKD admitted for HF are linked with increased mortality, in-hospital complications, higher costs, and a longer length of stay compared to non-Asian patients. Methods: This retrospective study included patients 18 or older with heart failure and CKD 3-5 on discharge from 2016 to 2019. Multivariate logistic regression calculated the odds ratio (OR) adjusting for Elixhauser co-morbidities, age, and sex. The primary outcome was disparities in racial/ethnic, sex, and age of in-hospital mortality of patients admitted for HF complicated by CKD. Results: This study involved 510,525 patients, revealing Hispanics (OR: 0.791; CI: 07125-0.8747; p<0.001) and African Americans (OR: 0.664; CI: 0.608-0.7258; p<0.001) were associated with significantly lower mortality compared to Asians. Controlling for age and gender, Asians with HF & CKD had significantly higher odds of diabetes, hyperlipidemia, and hypertension compared to non-Asians. Asian males with HF and CKD were associated with significantly higher odds of mortality (OR: 1.072; CI: 1.037-1.109; p<0.001) and cardiovascular co-morbidities including atrial fibrillation, coronary bypass graft, implantable pacemaker, and chronic ischemic heart disease compared to non-Asian males. Asians, compared to non-Asians, were associated with significantly higher odds of acute MI, acute kidney injury, sepsis, and PRBC transfusion when controlling for Elixhauser co-morbidities. Conclusions: This study reveals significant health disparities among Asian patients with HF and CKD. The significant difference in odds of mortality and cardiovascular co-morbidities indicates the need for further research regarding the possible causality of such disparities.

Transit-time flowmetry measurement features of coronary bypass grafts after multiple percutaneous coronary interventions

The functionality of coronary bypass grafts after surgical myocardial revascularization in patients with coronary heart disease directly depends on the state of the target coronary arteries. In the presence of widespread and diff use atherosclerotic lesions or microcirculatory dysfunctions, a high frequency of coronary bypass dysfunctions is noted in the near future. In some cases, shunt dysfunction can lead to severe hemodynamic instability, accompanied by acute circulatory disorders.Aim: To assess the function of coronary bypass grafts during myocardial revascularization using the method of ultrasonic flowmetry in patients with and without a history of multiple percutaneous coronary interventions (PCI).Material and methods. The retrospective study included 47 patients who underwent coronary artery bypass surgery. A total of 145 coronary bypass grafts were performed. All patients were divided into 2 groups. Group 1 (PCI group) included patients after multiple previous PCI (n = 25; 74 coronary bypass grafts), group 2 (without PCI) included patients without previous PCI (n = 22; 71 coronary bypass grafts). All patients underwent intraoperative ultrasonic flowmetry of coronary bypass grafts using the VeriQ system (Medistim, Norway).Results. When analyzing the status of coronary bypass grafts in patients after multiple PCI, a significantly low mean volumetric blood flow rate was noted (29.5 ± 8.3 ml/min and 48.2 ± 11.6 ml/min, respectively, p = 0.0001) and lower diastolic filling (55.2 ± 8.2% and 71.9 ± 7.1%, p = 0.0001). Also in the group of patients after multiple PCI, there were 2 (2.7%) cases of revision of the distal anastomosis due to a high pulsatile index and low volumetric blood flow velocity. However, no such events were noted in the group without PCI.Conclusions. Previous percutaneous coronary interventions are compromising factors for the state of the coronary bed, which reduces the functional status of coronary bypass grafts and may increase the perioperative risk of surgical myocardial revascularization.

Do chronic total occlusive lesions affect patency of coronary bypass grafts to the right coronary artery?

To evaluate the impact of chronic total occlusion (CTO) lesions on the patency of bypass grafts to the right coronary artery territory. Two hundred patients undergoing primary isolated coronary artery bypass grafting with revascularization to the right coronary artery territory between April 2015 and July 2022 were retrospectively analyzed. Study patients were divided into two groups according to their right coronary artery lesion: patients with CTO lesions (n = 76) and those without CTO lesions (n = 124). Graft flow of the right coronary artery territory was evaluated by intraoperative transit time flow measurement and patency of the bypass graft was evaluated by multidetector row computed tomography. A total of 200 patients (76 patients with CTO and 124 patients without CTO) were included in this study. Intraoperative transit time flow measurement demonstrated that there was no significant difference in the median mean graft flow (30 ml/min vs. 25 ml/min; p = 0.114), pulsatility index (2.1 vs. 2.4; p = 0.079), and diastolic filling rate (65% vs. 64%; p = 0.844) between patients with CTO and those without CTO. Postoperative multidetector row computed tomography demonstrated that the patency of bypass grafts to the right coronary artery territory was similar between the groups (94.7% in patients with CTO vs. 96.0% in those without CTO; p = 0.733). In patients with CTO, the patency of bypass graft tended to be worse in subgroup with rich collateral blood flow (Rentrop grade 3). Chronic total occlusion lesions do not affect the patency of bypass grafts to the right coronary artery territory.

Minimally invasive multi-vessel coronary artery bypass grafting and concomitant mitral valve replacement via bilateral mini-thoracotomy: An alternative to sternotomy

Minimally invasive methods continue to become increasingly common in cardiac surgery. In particular, the utilization of thoracotomy in multi-vessel coronary bypass grafting and valve surgery has accelerated, but sternotomy is still applied in combined pathologies. A 76-year-old male patient underwent multi-vessel coronary artery bypass grafting and mitral valve replacement without sternotomy using bilateral mini-thoracotomy, as the patient was old, frail, and had many comorbid factors. In conclusion, this minimally invasive approach can decrease all postoperative complications, accelerate patient recovery, and achieve good cosmetic results.

Unexpected Impact of Preoperative Anemia in Low-Risk Isolated CABG or Single Valve Surgical Patients: Do Not Overlook These Patients in Anemia Management!

Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons predicted risk of mortality (STS PROM). The study consisted of adult, isolated coronary bypass grafting (CABG) or single valve surgical patients in a statewide registry from 2011-2022 (N=29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. Median age was 66 (58-73) yrs, STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n=23,261), 10% isolated mitral valve repair/replacement (n=3,119), 12% isolated aortic valve replacement (n=3,448), and 29% were female (n=8,646). Multivariable analyses found that higher Hct was associated with reduced risk of STS-defined morbidity/mortality (OR=0.96, P<0.001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (OR=1.01, P<0.001). There was a stronger association between Hct levels and morbidity/mortality risk in the lowest STS risk patients compared to the highest STS risk patients. Lower risk patients had a greater association between preoperative Hct and major morbidity and mortality compared to higher risk patients. Preoperative anemia management is essential across all risk groups for improved outcomes.

Comparison of percutaneous coronary intervention of native coronary artery versus bypass graft in patients with prior coronary artery bypass grafting.

Large number of patients with prior coronary artery bypass grafting (CABG) need repeat revascularization yearly, and percutaneous coronary intervention (PCI) is the optimal treatment strategy for such patients. However, it is still controversial whether PCI of native coronary artery or bypass graft is more beneficial. The aim of the study was to compare the clinical outcomes between native coronary artery vs. bypass graft PCI in patients with prior CABG. A total of 1,276 patients with prior CABG who underwent index PCI of native coronary artery (n=1,072) or bypass graft (n=204) were retrospectively examined. Patients were divided into native group and graft group according to the target vessel. The outcomes of the two groups were compared by using inverse probability of treatment weighting (IPTW) and Cox regression analysis. The primary endpoint was the composite of major adverse cardiac and cerebrovascular events (MACCEs), which included all-cause death, non-fatal stroke, non-fatal myocardial infarction (MI), or target vessel revascularization (TVR). Compared with native group, patients in graft group had higher risk of slow-flow/no-reflow phenomenon (1.5% vs. 0.1%, P=0.011 before IPTW, and 2.2% vs. 0.1%, P<0.001 after IPTW) and peri-procedural stroke (0.3% vs. 0, P=0.021 after IPTW). During a median follow-up period of 43 months, there was similar risk of MACCE between two groups. Notably, patients in graft group had a significantly higher incidence of non-fatal MI compared with native group regardless with or without IPTW (7.8% vs. 3.8%, P=0.018 and 8.3% vs. 3.9%, P=0.030, separately). After adjusting for confounding by using Cox regression, bypass graft PCI was associated with a higher risk of non-fatal MI (HR: 2.091, 95% CI: 1.069-4.089; P=0.031), but similar results in MACCE (HR: 1.077, 95% CI: 0.817-1.419; P=0.599) compared with native group. This study found that native coronary artery might be preferred for PCI in patients with prior CABG because of lower rates of slow-flow/no-reflow, peri-procedural stroke, and non-fatal MI at follow-up.

Pre-arterialization of coronary veins prior to retroperfusion of ischemic myocardium: percutaneous closure device.

Chronic coronary retroperfusion to treat myocardial ischemia has previously failed due to edema and hemorrhage of coronary veins suddenly exposed to arterial pressures. The objective of this study was to selectively adapt the coronary veins to become arterialized prior to coronary venous retroperfusion to avoid vascular edema and hemorrhage. In 32 animals (Group I = 19 and Group II = 13), the left anterior descending (LAD) artery was occluded using an ameroid occlusion model. In Group I, the great cardiac vein was blocked with suture ligation (Group IA = 11) or with occlusion device (Group IB = 8) to arterialize the venous system within 2 weeks at intermediate pressure (between arterial and venous levels) before a coronary venous bypass graft (CVBG) was implemented through a left internal mammary artery (LIMA) anastomosis. Group II only received the LAD artery occlusion and served as control. Serial echocardiograms showed recovery of left ventricular (LV) function with this adaptation-arterialization approach, with an increase in ejection fraction (EF) in Group I from 38% ± 5% after coronary occlusion to 53% ± 7% eight weeks after CVBG, whereas in Group II the EF never recovered (41% ± 2%-33% ± 7%). The remodeling of the venous system not only allowed restoration of myocardial function when CVBG was implemented but possibly promoted a novel form of "collateralization" between the native arterioles and the newly arterialized venules, which revascularized the ischemic myocardium. These findings form a potential rationale for a venous arterialization-revascularization treatment for the refractory angina and the "no-option" patients using a hybrid percutaneous (closure device for arterialization)/surgical approach (CVBG) to revascularize the myocardium.

ПРЕДИКТОРЫ ГОСПИТАЛЬНЫХ ОСЛОЖНЕНИЙ И ДЛИТЕЛЬНОЙ ГОСПИТАЛИЗАЦИИ У ПАЦИЕНТОВ, ПЕРЕНЕСШИХ КОРОНАРНОЕ ШУНТИРОВАНИЕ: РОЛЬ СВОБОДНЫХ ЖИРНЫХ КИСЛОТ И ИНДЕКСОВ ИНСУЛИНОРЕЗИСТЕНТНОСТИ

Introduction. Often, carbohydrate metabolism disorders (type 2 diabetes mellitus, prediabetes) are detected in patients with severe coronary heart disease who are preparing for elective coronary bypass surgery. Insulin resistance can occur even in the absence of manifest disorders of carbohydrate metabolism and have its own influence on the course of coronary artery disease. With regard to the prognosis of coronary artery bypass grafting, the role of insulin resistance is not clearly defined, there are isolated reports on the relationship between the estimated indices of insulin resistance and free fatty acids and the number of postoperative complications of CABG Purpose of the study. To study the effect of carbohydrate metabolism disorders and insulin resistance indicators on the immediate results of coronary bypass grafting (CABG). Materials and methods. 383 consecutive patients who underwent CABG in 2011-2012 at the Research Institute of the KPSSZ were included, free fatty acids and fasting insulin in plasma were determined in all patients, insulin resistance indices HOMA-IR (Homeostasis Model Assessment of Insulin Resistance), QUICKI (Quantitative Insulin Sensitivity Chek) were calculated Index) and Revised-QUICKI, McAuley. A logistic regression analysis was performed to identify predictors of the composite endpoint of hospital stay after CABG &gt;10 days or significant complication. Perioperative characteristics were analyzed in two cohort groups: group 1 - patients with a combined endpoint (CCT&gt;10 days), n=291, and group 2 (n=92) without CCT. Results. In the CCT group, the median age was higher, and the proportion of women was 30% versus 14.1% (p=0.003). Patients of the 1st group (with CCT) had a higher percentage of type 2 diabetes mellitus (37.5% versus 17.4%, p&lt;0.001, more people with obesity (p&lt;0.001) and a higher percentage of combined operations (p =0.007) In group 1 (with CCT), the median of glucose (p=0.031), glycated hemoglobin HbA1c (p=0.009), free fatty acids (p=0.007) and Revised-QUICKI (p=0.020) was higher than In a binary regression, the predictors of the combined endpoint (significant complications or hospital stay after CABG &gt;10 days) were female gender, age, left atrial size, and free fatty acids before surgery (p&lt;0.001). per 1 mmol l, the probability of the endpoint increased by 255.9%, and with an increase in LA by 1 cm - by 219.5%, each year of age added 6.9% to the probability of the index event.For this model, the statistical significance was χ2 (2 ) = 38.337, p&lt;0.001 The Nagelkerke R2 value was 0.336 (explaining 33.6% of the combined variance of the results) and the model correctly classified 78.5% of the cases. At the same time, fasting glucose, insulin, lipid levels, HOMA, QUICKI, Revised-QUICKI, McAuley indices did not show their relationship with the studied outcome. Conclusions: In the group with a complicated postoperative period of CABG, there were significantly more women, patients with DM 2, and obese individuals, there was a higher median of free fatty acids and the Revised-QUICKI index. Free fatty acids and type 2 diabetes mellitus were independent predictors of hospital complications or length of stay after CABG.

ИММУНОФЕНОТИП МЕЗЕНХИМАЛЬНЫХ СТВОЛОВЫХ КЛЕТОК ЖИРОВОЙ ТКАНИ ПАЦИЕНТОВ С СЕРДЕЧНО СОСУДИСТЫМИ ЗАБОЛЕВАНИЯМИ

Introduction. Due to a set of unique properties, for example, the ability to differentiate into different types of connective tissue cells, mesenchymal stem cells (MSCs) are attracting more and more attention from researchers. In 2001, stem cells were found in the stromal-vascular fraction of adipose tissue, which, unlike bone marrow MSCs, show a higher tissue density, grow faster, and are available in large numbers when collected from a small amount of adipose tissue. Currently, a large number of studies are devoted to the study of the morphology and immunophenotype of subcutaneous and visceral adipose tissue stem cells (ASSCs) due to the possibility of easy cell production. Experimental work aimed at studying MSCs of cardiac localization is currently insufficient. Objective: to evaluate the immunophenotype of adipose tissue stromal cells isolated from epicardial and perivascular fat depots in patients with coronary heart disease and acquired heart defects. Materials and methods. The study included 5 patients with ischemic heart disease and 5 with acquired heart disease. The average age is 64.5±2.5 years. All patients had indications for open heart intervention - direct myocardial revascularization by coronary bypass grafting (CABG) or heart valve surgery. SCZhT from subcutaneous, epicardial and perivascular VT biopsies (3-5 years) obtained from patients during surgery (CABG or correction of heart defects) and isolated according to the method of Zeng G. [Zeng G. et al., 2013] . When cells grew to 80–90% confluence, they were digested with 0.25% trypsin and subjected to continuous cell growth and proliferation for subsequent experimental analyses. Flow cytometry analysis was performed on passage 2 cells. Results: The obtained results showed that the MSC culture of the 2nd passage was characterized by increased expression of CD73, CD90, CD105 antigens. Approximately 90% of passage 2 cells derived from epicardial adipose tissue (EAT) and perivascular adipose tissue (PVAT) from a patient with coronary heart disease (CHD) expressed classical MSC markers (CD73, CD90, CD105). In EAT cell culture in a patient with acquired heart disease (ACD), we observed a lower level of co-expression of the main markers of stem cells, in contrast to a patient with CHD (CD90 and CD105 about 61% of cells, and CD90 and CD73 - 58.72%) . The percentage of the studied stem markers on cells isolated from PVAT in a patient with heart disease did not differ significantly from the level of expression of these markers in a patient with coronary artery disease. The level of CD34 expression varied depending on the localization of VT and the disease: thus, in patients with coronary artery disease, the level of CD34 did not exceed 3.5% in both epicardial and perivascular VT. At the same time, a higher percentage of CD34 (32.32%) was found in the epicardial adipose tissue of a patient with PPS. It should be noted that in addition to the main population, both in the EAT culture and in the PVAT, there were 2 minor ones: 1 - CD 90- CD 105+ CD 34-/+ CD 73+ - presumably endothelial population, 2 - CD 90+ CD 105- CD 34- CD 73- - the smallest population. Conclusion: In the early stages of cultivation, cells of the stromal-vascular fraction isolated from epicardial and perivascular adipose tissue express surface markers characteristic of adipose tissue stem cells.

Non-contrast computed tomography findings for identification of chronically occluded coronary artery bypass grafts.

Detecting occlusions of coronary artery bypass grafts using non-contrast computed tomography (CT) series is understudied and underestimated. To evaluate morphological findings for the diagnosis of chronic coronary artery bypass graft occlusion on non-contrast CT and investigate performance statistics for potential use cases. Seventy-three patients with coronary artery bypass grafts who had CT angiography of the chest (non-contrast and arterial phases) were retrospectively included. Two readers applied pre-set morphologic findings to assess the patency of a bypass graft on non-contrast series. These findings included vessel shape (linear-band like), collapsed lumen and surgical graft marker without a visible vessel. Performance was tested using the simultaneously acquired arterial phase series as the ground truth. The per-patient diagnostic accuracy for occlusion was 0.890 (95% confidence interval=0.795-0.951). Venous grafts overall had an 88% accuracy. None of the left internal mammary artery to left anterior descending artery arterial graft occlusions were detected. The negative likelihood ratio for an occluded graft that is truly patent was 0.121, demonstrating a true post-test probability of 97% for identifying a patent graft as truly patent given a prevalence of 20% occlusion at a median 8.4 years post-surgery. Neither years post-surgery, nor number of vessels was associated with a significant decrease in reader accuracy. Evaluation of coronary bypass grafts for chronic occlusion on non-contrast CT based off vessel morphology is feasible and accurate for venous grafts. Potential use cases include low-intermediate risk patients with chest pain or shortness of breath for whom non-contrast CT was ordered, or administration of iodine-based contrast is contraindicated.

Apolipoprotein A-I vascular gene therapy reduces vein-graft atherosclerosis

Coronary artery venous bypass grafts typically fail because of atherosclerosis driven by lipid and macrophage accumulation. Therapy for vein-graft atherosclerosis is limited to statin drugs, which are only modestly effective. We hypothesized that transduction of vein-graft endothelium of fat-fed rabbits with a helper-dependent adenovirus expressing apolipoprotein AI (HDAdApoAI) would reduce lipid and macrophage accumulation. Fat-fed rabbits received bilateral external jugular vein-to-carotid artery interposition grafts. Four weeks later, one graft per rabbit (n= 23 rabbits) was infused with HDAdApoAI and the contralateral graft with HDAdNull. Grafts were harvested 12weeks later. Paired analyses of grafts were performed, with vein graft cholesterol, intimal lipid, and macrophage content as the primary endpoints. HDAd genomes were detected in all grafts. APOAI mRNA was median 63-fold higher in HDAdApoAI grafts versus HDAdNull grafts (p<0.001). HDAdApoAI grafts had a mean 15% lower total cholesterol (by mass spectrometry; p= 0.003); mean 19% lower intimal lipid (by oil red O staining; p= 0.02); and mean 13% lower expression of the macrophage marker CD68 (by reverse transcriptase-mediated quantitative PCR; p= 0.008). Invivo transduction of vein-graft endothelium achieves persistent APOAI expression and reduces vein-graft cholesterol, intimal lipid, and CD68 expression. Vascular gene therapy with APOAI haspromise for preventing vein-graft failure caused by atherosclerosis.

Coronary Bypass Grafting to Allow Revascularisation of the Lower Limbs, or Vice Versa?

Coronary Bypass Grafting to Allow Revascularisation of the Lower Limbs, or Vice Versa?

Atrial fibrillation after coronary bypass graft - what do we know now?

Introduction: Atrial fibrillation (AF) is the most common supraventricular arrhythmia in clinical practice. The percentage of people with AF increases with age. The currently implemented procedure for detecting modifiable risk factors allows for early implementation of a therapeutic plan in primary and secondary prevention. The following work deals with the occurrence of atrial fibrillation, risk factors and ways of coping with the disease in patients undergoing coronary artery bypass grafting (CABG). Materials and methods: The literature available on PubMed and Google Scholar was reviewed using the words „atrial fibrillation”, „coronary artery bypass grafting”. Summary: Patients undergoing coronary artery bypass surgery are at risk of developing postoperative atrial fibrillation. This is especially true for older patients with additional burdens, such as past arrhythmia episodes, hypertension, critical stenosis of the right coronary artery.