Coronary Bypass Surgery Patients Research Articles

Graft Choice and Timing of Coronary Bypass Surgery in Patients with Vasculitis Syndromes: Two Cases Report

Abstract Polyarteritis nodosa is multisystem disease with necrotizing vasculitis of middle and small sized arteries. Takayasu arteritis is a rare nonspecific inflammatory disease with unknown cause, predominantly affecting the aorta and its main branches. In the literature, experience about the appropriate graft selection and the long-term patency is reported for vasculitis syndromes such as Takayasu’s arteritis but there were no data for Polyarteritis Nodosa. In this article we review the graft choice for patients with vasculitis syndromes and our coronary revascularization surgery experience with two patients, one with Polyarteritis Nodosa and the other with Takayasu’s arteritis. There has not yet a consensus on graft choice for patients with vasculitis syndromes and it will be possible more accurate assessment if the number of cases increases. Key words: Polyarteritis Nodosa, Takayasu arteritis, coronary artery bypass grafting, vasculitis

The effect of mild left ventricular diastolic dysfunction on outcome after isolated coronary bypass surgery

Although moderate to severe diastolic dysfunction (DD) seems to be associated with poor prognosis after isolated coronary bypass surgery, the impact of mild DD has not been investigated extensively in this group of patients. We evaluated the prognostic implication of mild left ventricular (LV) DD on outcome after isolated coronary bypass surgery in patients with preserved LV systolic function. Data from 650 patients undergoing isolated coronary bypass surgery and having records for LV diastolic function between January 2009 and August 2011 was collected retrospectively. DD was classified as mild (grade 1, impaired relaxation), moderate (grade 2, decreased compliance) or severe (grade 3-4, restrictive pattern) depending on mitral inflow wave, tissue Doppler imaging, and pulmonary vein flow wave. Patients with baseline rhythm other than sinus, moderate or severe valvular dysfunction, moderate or severe diastolic dysfunction, and LV ejection fraction lower than 50% were excluded. A total of 472 patients were identified within the database fulfilling the eligibility criteria for this analysis and stratified according to the echocardiographic findings as follows: group 1 comprised patients with normal diastolic function (n = 168); and group 2 was made up of patients with mild DD (impaired relaxation) (n = 304). These groups were compared for perioperative morbidity and mortality. The preoperative variables were comparable between groups. The outcome parameters of group 1 was similar compared to group 2 in terms of need for inotropic support (20.2% vs. 16.2%), intra-aortic balloon pump usage (0% vs. 1.4%), mechanical ventilation time (8.94 ± 0.96 h vs. 10.0 ± 0.89 h), reintubation rate (1.8% vs. 1.4%), intensive care unit stay time (24.1 ± 1.4 hvs. 26.2 ± 1.9 h), postoperative renal failure rate (0% vs. 0.3%), postoperative atrial fibrillation rate (10.1% vs. 11.2%), length of hospital stay (7.19 ± 0.45 vs. 6.57 ± 0.14 days), hospital readmission rate (3.1% vs. 3.1%), and mortality (0% vs. 1.6%). The results from this study indicate that mild LV DD is not associated with adverse outcome after coronary bypass surgery in patients with preserved LV systolic function, thus should not be considered as a preoperative risk factor.

The results of the second year of carotid stenting

Introduction-objectives: Carotid artery stenting (CAS) process, especially in highrisk patients, is carotid endarterectomy (CEA) alternative. Our aim in this study, the reliability of CAS process, to evaluate the clinical and radiological results of the second year. Method: 120 patients [mean age 68 (48-86)] who have admitted to our hospital between December 2010 and March 2013 and CAS decision taken, were included in the study. Patients with symptomatic carotid artery and 50% of those with stenosis, patients with asymptomatic carotid artery stenosis greater than 70% were included. 80% of asymptomatic patients, coronary bypass surgery in patients who had precreated screen-detected. 75% of symptomatic patients, 81% of coronary artery disease, 64% of hypertensive, was 44% of the diabetic. 81% of male patients in our study group, the rate of smoking was 40%. Patients were on average 21 months (2-28 months), were followed. All the patients before the procedure, carotid doppler ultrasound and patients who require computed tomography (CT) angiography, was performed. Ultrasound, instent peak flow velocity 224 cm/sec and CT angiography in the detection of stenosis 50% was considered as restenosis. CAS operation, 62% of patients, proximal-lock braking system (Mo.Ma ), 38% in the distal embolic protection device (Anjioguard ) was used. 23% of patients (28 patients) had bilateral carotid artery stenosis. Of these patients, 19 of them lock braking system proximal, distal embolic protection device was used in 9 of them. 9 patients (7%) 100% against the carotid artery was occluded. Distal embolic protection devices were used in these patients. Results: One patient (0.8%) 24 hours after treatment, cerebrovascular ischemic events with sequelae, developed. Patients were followed up for neurology and medical recommendation. 2 patients (1.7%), 6 and 11 months after treatment of transient ischemic attack (TIA) is observed. TIA patients undergoing open carotid stents was observed, in one of these patients with paroxysmal atrial fibrillation was detected and warfarin medication was started, other patients cranial angiography, intracerebral lesions in the arteries viewed and neurology clinic with the proposal of a serious medical follow-up was continued. 3 (2.5%) patients were asymptomatic, 12th month restenosis were detected with doppler ultrasound scans and confirmed by CT angiography. Two of the patients with restenosis, one of them %60 stent restenosis in carotid artery, while the other was at the level of 80%. For patient who has 80% stenosis lesion, CEA procedures were performed. Symptomatic restenosis was not observed. Conclusion: CAS-treated patients in our clinic, the success and complication rates are similar to other studies.The largest share of low complication and high success rates, getting experience in our clinic, patient selection and follow-up with neurology and radiology clinics provide an important contribution are made in the opinion.

Oxidative stress and nitric oxide pathway in adult patients who are candidates for cardiac surgery: patterns and differences

We investigated whether oxidative stress and the arginine/nitric oxide pathway differ in control subjects and in adult patients who are candidates for the three most common cardiac surgical operations: coronary bypass surgery, aortic valve replacement for calcific non-rheumatic aortic stenosis or mitral valve repair for degenerative mitral insufficiency. In this prospective observational study, we studied 165 consecutive patients undergoing surgery from January to June 2011 (coronary bypass surgery, n = 63; aortic valve replacement for calcific non-rheumatic aortic stenosis, n = 51; mitral valve repair for degenerative mitral insufficiency, n = 51). Thirty-three healthy subjects with cardiovascular risk factors similar to surgery patients were also studied (Controls). Oxidative stress (the ratio of reduced and oxidized glutathione and urinary isoprostane), antioxidants (alpha- and gamma tocopherol) and factors involved in nitric oxide synthesis (arginine, symmetric and asymmetric dimethylarginine) were measured before surgery. Analysis of variance general linear models and principal component analysis were used for statistical analysis. Surgical patients had increased levels of oxidative stress and decreased levels of antioxidants. Increased levels of nitric oxide inhibitor asymmetric dimethylarginine were detected in surgical candidates, suggesting arginine/nitric oxide pathway impairment. Concerning the differences among surgical procedures, higher oxidative stress and a major imbalance of the ratio between substrate and inhibitors of nitric oxide synthesis were evidenced in patients who were candidates for mitral valve repair with respect to coronary bypass surgery patients and patients with calcific non-rheumatic aortic stenosis. Patients undergoing cardiac surgery have increased oxidative stress and a trend towards an impaired arginine/nitric oxide pathway with respect to Controls. Patients affected by mitral valve regurgitation show more pronounced perturbations in these pathways. The clinical implications of these findings need to be investigated.

Does the use of triclosan-coated sutures really reduce surgical site infection after open vein bypass grafting patients?

We read with interest Thimour-Bergstrom et al.’s recent article [1] on the randomized trial evaluating the effect of triclosan-coated sutures on the rate of surgical site infection (SSI) after open vein bypass grafting procedures. The authors’ report that leg-wound closure with triclosan-coated sutures reduces the SSI rate in coronary artery bypass surgery (CABG) patients after open vein harvesting. The study was double-blinded. The antibiotic prophylaxis and surgical wound methods were standardized. All wounds were inspected by a specially trained research nurse at 4 and 30 days after surgery and evaluated according to the Centre for Disease Control (CDC) definition of SSI [2]. On the 60th postoperative day the patients were interviewed by telephone and, if a patient reported any type of wound-healing problems, they were seen at the outpatient clinic. The incidence of SSI on the 30th and the 60th postoperative days was 9 and 12.5% in the triclosan-coated suture group and 13 and 20% in the control group, respectively. Their study has some limitations that make us unable to agree with the conclusion that triclosan-coated sutures reduce the risk of SSI after vein harvesting in CABG patients. First, the diagnosis of SSI according to the CDC definition should be made within 30 days of surgery. In this study, the difference in the incidence of SSI on the 30th postoperative day was only 4%. However, Thimour-Bergstrom et al. reported the diagnoses that were made on the 60th postoperative day. Furthermore, the primary diagnosis of SSI on the 60th postoperative day was made by a patient, not by a surgeon. Secondly, the authors reported the result of univariate analysis only. The number of bypasses was 3.0 in the triclosan group and 3.2 in the control group, P = 0.008. Furthermore, the number of bypasses was 3.4 among patients who developed leg infection and 3.1 among patients who did not develop leg infection P = 0.014. It is possible that the number of bypasses (because of the longer graft and operation time required) would have been an independent risk factor for infection rather than use of nontriclosan suture if the multivariate analysis were performed. Thirdly, the study was financially supported by Ethicon, Inc., Somerville, NJ, USA, the company providing triclosan-coated sutures. Thimour-Bergstrom et al. have conducted a finely designed study. However, the results of the 30th postoperative day should have been reported and a multivariate analysis of risk factors should have been performed. Appropriate analysis might have led to a conclusion that the use of triclosan-coated sutures does not reduce the risk of wound infection rate in CABG patients after open vein harvesting.

Time from adenosine di-phosphate receptor antagonist discontinuation to coronary bypass surgery in patients with acute coronary syndrome: Meta-analysis and meta-regression

Adenosine di-phosphate receptor antagonists (ADPRAs) blunt hemostasis for several days after administration. This effect, aimed at preventing cardiac ischemic complications particularly in patients with acute coronary syndromes (ACS), may increase perioperative bleeding in the case of cardiac surgery. Practice Guidelines recommend withholding ADPRAs for at least 5days prior to surgery, though with a weak base of evidence. The purpose of this study was to systematically review observational and experimental studies of early or late preoperative discontinuation of ADPRAs prior to coronary artery bypass grafting (CABG) for patients with ACS. MEDLINE, EMBASE, the Cochrane Library databases up to December 2011; and reference lists. Observational and experimental studies that compared early ADPRA discontinuation with late discontinuation, or no discontinuation, in patients with ACS undergoing CABG. There were 19 studies, including 14,046 participants, 395 deaths and 309 reoperations due to bleeding. ADPRA late discontinuation up to CABG was associated with an increased risk of postoperative mortality (OR 1.46, 95% confidence interval (CI) 1.10 to 1.93) and reoperations due to bleeding (OR 2.18; 95% CI 1.47 to 2.62). Between-study heterogeneity was low. Meta-analysis limited to high quality or prospective studies gave consistent results. In most instances, the 95% prediction intervals for summary risk estimates confirmed the risk across study groups. ADPRA late discontinuation prior to CABG is associated with an increased risk of death and reoperations due to bleeding in patients with ACS. The confidence in the estimates of risk for late discontinuation is moderate to high.

Preoperative Anemia Does Not Increase the Risks of Early Surgical Revascularization After Myocardial Infarction

Recent clinical studies suggest preoperative anemia may increase mortality and morbidity after cardiac surgery. Anemic patients are potentially even more vulnerable in the setting of a recent myocardial infarction (MI). The objective of this study was to investigate the impact of preoperative anemia on short-term outcomes after coronary bypass surgery in patients with a recent MI. We conducted a retrospective cohort study of 655 patients who underwent an isolated coronary bypass procedure within 21 days of MI, 432 of whom were anemic preoperatively, defined as a hemoglobin less than 13 g/dL for men and less than 12 g/dL for women. The primary outcomes were in-hospital mortality and major adverse events (MAE), which included MI, stroke, and renal failure requiring dialysis. Before risk adjustment, in-hospital mortality and the incidence of MAE were significantly higher in patients with anemia versus no anemia (mortality, 5.1% versus 1.4%, p = 0.02; MAE, 8.6% versus 3.1%, p = 0.009). After risk adjustment, the association between preoperative anemia and mortality or MAE became insignificant (mortality odds ratio 2.34, 95% confidence interval: 0.56 to 9.87, p = 0.25; MAE odds ratio 1.13, 95% confidence interval: 0.46 to 2.79, p = 0.78). Preoperative hemoglobin, treated as a continuous variable, yielded similar results. Preoperative anemia does not directly increase risks of surgical revascularization performed within 21 days of MI.

Editorial Comment: Acute kidney injury on normally functioning kidneys and long-term mortality after coronary bypass surgery

Editorial Comment: Acute kidney injury on normally functioning kidneys and long-term mortality after coronary bypass surgery

No “I” in Heart Team

The landmark Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial, comparing drug-eluting stents with coronary bypass surgery in patients with complex coronary artery disease, was published in 2009.1 Although the trial continues to provide valuable insights regarding selection of coronary revascularization procedures, a particular aspect of its protocol has also generated considerable attention: the “Heart Team.” Although not the first to suggest it, the Heart Team concept was recently popularized by the SYNTAX investigators in their attempt to accommodate an “all-comers” design, streamlining the process for patient selection that had burdened coronary revascularization trials in the past. Instead of using an exhaustive list of explicit inclusion and exclusion criteria, the study protocol simply required that, for the most part, a cardiac surgeon and an interventional cardiologist came together in consensus about the appropriateness of enrolling a patient. Although the idea of using Heart Teams in this manner did not originate with the SYNTAX trial, the special emphasis placed on it by the investigators was unique and identified as such, even early on, by editorialists and prominent clinicians.2,3 As a result, the notion of encouraging multidisciplinary care in cardiovascular medicine, exemplified by the Heart Team concept, has gained increasing traction in the context of a broad range of procedures that encompass coronary revascularization, transcatheter aortic valve replacement (TAVR), and other complex endovascular interventions. It is widely discussed in the published literature, highlighted at scientific conferences, and, most prominently, incorporated into professional society guidelines. In recent guidelines for coronary revascularization, for example, use of a Heart Team is a class I recommendation during the decision-making process for patients with complex coronary artery disease.4,5 So, what exactly is a Heart Team? In the SYNTAX trial, the idea simply referred to the requirement that, at …

Adaptation and implementation of an evidence-based behavioral medicine program in diverse global settings: The Williams LifeSkills experience

Epidemiological research has documented the health-damaging effects of psychosocial factors like hostility, depression, anxiety, job stress, social isolation and low socioeconomic status. Several studies suggest that behavioral interventions can reduce levels of these psychosocial factors. Herein we describe the translational process whereby the Williams LifeSkills® (WLS(®)) program and products for reducing psychosocial risk factors have been developed and tested in clinical trials in the U.S. and Canada and then adapted for other cultures and tested in clinical trials in other countries around the world. Evidence from published controlled and observational trials of WLS(®) products in the U.S. and elsewhere shows that persons receiving coping skills training using WLS(®) products have consistently reported reduced levels of psychosocial risk factors. In two controlled trials, one for caregivers of a relative with Alzheimer's Disease in the U.S. and one for coronary bypass surgery patients in Singapore, WLS(®) training also produced clinically significant blood pressure reductions. In conclusion, WLS(®) products have been shown in controlled and observational trials to produce reduced levels of both psychosocial and cardiovascular stress indices. Ongoing research has the potential to show that WLS(®) products can be an effective vehicle for the delivery of stress reduction and mental health services in developing countries.

The effect of milrinone on the intraoperative hemodynamics during off-pump coronary bypass surgery in patients with an elevated echocardiographic index of the ventricular filling pressure

BackgroundHemodynamic derangement during off-pump coronary artery bypass surgery (OPCAB) is mainly attributed to impaired filling and diastolic dysfunction. An elevated ratio of the mitral velocity to the early-diastolic velocity of the mitral annulus (E/e' > 15) is a relatively new indicator of diastolic function, and this was reported to be associated with impaired hemodynamics during OPCAB. We investigated the efficacy of milrinone on the perioperative hemodynamics and short term outcomes of patients with an E/e' > 15 and who underwent OPCAB.MethodsThe patients were randomly allocated into either group C (control, n = 31) or group M (n = 31) and they were treated with the same amount of either normal saline or milrinone (0.5 µg/kg/min) without bolus loading after completion of internal mammary artery harvest until the end of operation. Hemodynamic measurements were recorded after the induction of anesthesia (T1), 5 min after starting each distal anastomosis of the left anterior descending artery (T2), left circumflex artery (T3) and right coronary artery (T4), and 5 min after sternum closure (T5).ResultsThe mixed venous oxygen saturation (SvO2) was lower through T2-T4 compared to the baseline value in both groups, while the degree of the decrease was significantly less in group M than that in group C. The other hemodynamic variables, the operative data and the postoperative outcomes were similar between the two groups.ConclusionsIntraoperative infusion of milrinone did not significantly improve the perioperative hemodynamics and the subsequent short term outcomes for the patients with preexisting diastolic dysfunction as represented by an elevated E/e' value, although it reduced the degree of decrease of the SvO2 during OPCAB.

Letter by Pocar et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

To the Editor: We congratulate Moller et al for outlining no major differences in short-term outcomes after off-pump versus conventional coronary bypass surgery in patients with European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥5.1 Mean additive EuroSCORE was 6.9, but no patient with ejection fraction <30% was enrolled, suggesting the prevalence of extracardiac risk factors in determining a higher risk profile. Although the …

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

Off-pump Coronary Bypass Surgery in Patients with Low Ejection Fraction

: Long-term survival after off-pump surgery in patients with low ejection fraction was investigated. : Three hundred forty-six patients with ejection fraction 30% or less with isolated off-pump coronary artery bypass surgery (OPCAB) were compared with a propensity matched historical group operated on-pump (ONCAB) and with data from literature after percutaneous coronary intervention and OPCAB surgery. : The lower invasiveness of OPCAB contributed to a significantly better 30-day survival, shorter postoperative length of stay, and fewer in-hospital complications. Incomplete revascularization of the posterior and lateral territories of the heart correlated with higher 1-year mortality. The probability of survival for 8 years after OPCAB was 50.1% (n = 76) versus 49.7% (n = 82) for ONCAB without comparable data from literature for OPCAB or percutaneous coronary intervention in these high-risk patients. : OPCAB surgery in patients with low ejection fraction is a viable alternative but so far without demonstrable long-term survival advantage to ONCAB.

Effect of preoperative statin therapy on myocardial protection and morbidity endpoints following off-pump coronary bypass surgery in patients with elevated C-reactive protein level

BackgroundThe aim of this study was to investigate the effects of preoperative statin therapy on myocardial protection and morbidity endpoints following off-pump coronary bypass graft surgery (OPCAB) in patients with elevated serum high-sensitivity C-reactive protein (hs-CRP) levels.MethodsOf the 492 patients who underwent multivessel OPCAB from March 2007 to February 2009, the records of 144 patients whose baseline hs-CRP level > 2 mg/L were reviewed. According to the history of preoperative statin therapy for at least one week, patients were classified as either statin group or control group (72 subjects each). Preoperative and operative characteristics and postoperative data including troponin (Tn)-T level and major morbidity endpoints were obtained and compared. Major morbidity endpoints were defined as permanent stroke, renal dysfunction, hemostatic re-exploration, deep sternal wound infection, and the number of patients requiring prolonged ventilation.ResultsPreoperative and operative characteristics were similar between the two groups. There were no significant differences in the incidence of morbidity endpoints between the two groups, except for the number of patients requiring dialysis, which was significantly lower in the statin group (8 vs. 1, P = 0.033). Tn-T level at 24 h after surgery was also significantly lower in the statin group.ConclusionsIn this study, we observed beneficial effects of preoperative statin therapy for at least one week in terms of less myocardial enzyme release and fewer patients requiring dialysis following OPCAB in patients whose preoperative hs-CRP was elevated.

Coronary bypass surgery in patients treated with clopidogrel. Is it safe?

Current guidelines for the management of acute coronary syndrome clearly recommend that clopidogrel should be started before diagnostic coronary angiography. If patients undergo coronary artery bypass grafting (CABG) early after clopidogrel loading or during continued exposure, it seems reasonable to expect an increase in bleeding complications. Earlier studies may have overestimated the risk of bleeding in patient undergoing CABG with prior clopidogrel exposure (5-10-fold increase). Some conflicting results are reported in literature. As reexploration because of excessive bleeding is concerned, a two to three-fold increase must be expected, which is demonstrated in actual trials properly matched to confounding factors. Discontinuation of clopidogrel for 5-7 days prior to urgent CABG as recommended by guidelines is not well adopted in clinical practice for several reasons. There is a moderately elevated risk of bleeding complications after CABG due to prior clopidogrel exposure alone. However, in clinical practice this risk is added often to patients who carry already elevated surgical risks (urgent procedures, worse coronary anatomy, history of previous myocardial infarction and prior percutaneous intervention), and after bleeding complications singular patients may suffer from consecutive adverse outcome. Cessation of clopidogrel in patients before CABG clearly prolongs hospitalization time and has an estimated 1% risk of coronary events during the waiting period. Risk and benefit have to be balanced in every individual case.

Problematik höhergradiger Karotisstenosen vor kardiochirurgischen Eingriffen – Konservative, katheterinterventionelle oder chirurgische Versorgung

There is a definitely increased risk of stroke during or after coronary bypass surgery in patients suffering simultaneously from carotid occlusive disease. In approximately 50 % of such cases the stroke is considered to be potentially due to the stenosis of the carotid artery. Some clinical centers have achieved good results with combined revascularization in cases of symptomatic carotid occlusive disease and in more than 80 % of non-symptomatic stenoses. However, the total rate of complications in such patients is relatively high, namely, approximately on a ten per cent level. An alternative could be an endovascular treatment with stent implantation before cardiac surgery. However, this demands specific pre-planning- due to the fact that it involves the need for inhibiting platelet aggregation. No definite recommendations can be given on the basis of available data. It would be desirable to have a randomized comparison of conservative and surgical (surgery or stenting) procedures, but this is hardly likely in view of the relatively few combined interventions. Hence, optimal treatment will continue to be determined by a multi-disciplinary team of internal medicine experts/cardiologists, surgeons, and interventional experts, individually for each patient and depending on local expertise.

Abstract 2083: Five-Year Follow-Up of Quality of Life in Randomized Patients to Receive Coronary Bypass Surgery, Percutaneous Coronary Intervention or Medical Treatment: The Medicine Angioplasty or Surgery Study (MASS-II) Trial

Background: Although coronary bypass surgery (CABG), percutaneous coronary intervention (PCI) are used for the relief of symptoms and for a better tolerance to exercises, there is no conclusive evidence showing that these methods offer more benefits than the medical treatment (MT) to the quality of life (QoL) in patients with symptomatic coronary artery disease (CAD). This study sought to compare the QoL scores during 5-year in patients with stable multivessel CAD, who underwent one of the 3 therapeutic approaches. Methods: From May 2000 and May 2005 a total of 611 patients were randomly assigned to a CABG (n=203), PCI (n=205) or MT (n=203). Of these patients, 546 (89%) were followed for assessments of QoL and demographic profile questionnaire for a 5-year period. 187 (34%) underwent CABG, 181 (33 %) PCI and 178 (33%) underwent MT. The Short Form Health-Related QoL Questionnaire (SF-36) was used to assess the patients, before randomization, six months, and 12months and annually until the end of study. The SF-36 comprises 36 items that can be combined into the following eight multi-item summary scores: physical functioning, vitality, bodily pain, mental heath, social functioning, and role limitation due to physical health, emotional problems and general health perceptions. Results: At baseline, we found no difference relating to overall mortality between three groups. The eight domains of QoL showed improvement in all groups at 6-month follow-up visit compared with the baseline evaluation (p&lt;0.001). Surgical therapy, PCI and MT showed improvements over baseline in most domains of quality of life (p&lt;0.001). The improvements was observed mainly in surgical group and especially in physical role functioning. On the other hand medical therapy group showed fewer changed in their rating of general health. PCI group showed significant superiority over medical group in terms of physical functioning, vitality and general health after randomization. Conclusion: All patients had improvement in QoL detected at 6 months persisting until 60 months. Moreover, CABG patients had better improvement of QoL compared with other groups. Furthermore, the QoL of PCI patients was better than MT patients at the end of follow-up.

Does radial use as a second arterial conduit for coronary artery bypass grafting improve long-term outcomes in diabetics?☆☆☆

The evidence supporting the survival benefit of multiple arterial grafts in the general coronary bypass surgery (CABG) population is compelling. Alternatively, results of studies comparing 2 versus 1 internal thoracic artery (ITA) grafts in diabetics have reported conflicting survival data. The use of radial versus ITA as the second arterial conduit has not been studied. We obtained complete death follow-up in 1516 consecutive diabetic [64+/-10 years (mean+/-SD). Insulin/no insulin: There were 540 (36%)/976 (64%)] primary isolated CABG patients all with >or=1 ITA grafts. The series included 626 ITA/radial (41%) and 890 ITA/vein (59%) patients. Using separate radial-use propensity models, we matched one-to-one 475 (76%) ITA/radial to 475 (53%) unique ITA/vein patients; each including 166 insulin and 309 no insulin patients. Unadjusted survival was markedly better for (1) ITA/radial (94.3%, 86.7% and 70.4% at 1, 5 and 10 years, respectively) versus ITA/vein (91.8%, 74.5% and 53.8%; p<0.0001) and (2) for no insulin (94.2%, 82.8% and 65.5%) versus insulin (90.4%, 73.1% and 49.2%; p<0.0001). In matched patients, 11-year Kaplan-Meier analysis showed essentially identical ITA/radial and ITA/vein survival for all diabetics combined (p=0.53; log rank) and for the no insulin (p=0.76) cohort. Lastly, a trend for better ITA/radial survival in insulin dependent diabetics after the second postoperative year did not reach significance (p=0.13). Using radial as a second arterial conduit as opposed to vein grafting did not confer a survival benefit in diabetics. This unexpected result is perhaps related to relatively diminished radial graft patency and/or the augmented radial vasoreactivity characteristic of diabetics. These findings indicate that the radial survival advantage demonstrated in the general CABG population lies primarily in non-diabetics in whom this advantage may be underestimated.

The effect of radial artery on coronary bypass surgery in patients aged 65 years and older

To investigate the effect of autologous radial artery (RA) on coronary artery bypass grafting (CABG) in the elderly aged 65 years and older. Three hundreds and twenty-two patients aged 65 years and older underwent CABG with autologous RA from January 2000 to March 2007. Peri-operative complication and mortality were observed and follow-up was performed. Three hundreds and forty-four RA grafts including 300 cases of single and 22 cases of bilateral RA were collected. The total number of distal anastomosis was 974, with the mean of (3.0 +/- 0.4). The mean of RA distal anastomosis was (1.1 +/- 0.4). There were 321 single, 16 Y or T composite and 7 sequential grafts of RA constructed. The distal end of RA was anastomosed to right coronary artery system for 234 times, to obtuse marginal for 95 times, to diagonal or intermediate ramous artery for 22 times. The proximal end of RA was anastomosed to aorta for 328 times, to left internal mammary artery for 9 times and to saphenous vein for 7 times. Only 13 patients manifested transient paresthesia in the area of radial aspect of thumb and no other complication occurred in the forearm. During hospitalization, 7 patients died. No patient died after the follow-up of (46.5 +/- 6.7) months. Seventy-three patients were performed with coronary angiography postoperatively. It was showed by coronary angiography that all RA conduits were patent after the duration of (47.5 +/- 11.2) months after CABG. Utilization of RA to CABG in the elderly is safe and effective.