Early Coronary Artery Bypass Grafting Research Articles

Evidence of the Advantages of Preoperative Intra-aortic Balloon Pump in Surgical Revascularization of Acute Myocardial Infarction

Background: Early coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) is associated with considerable risk. The optimal timing of surgery and the preoperative use of an intra-aortic balloon pump (IABP) in these patients remain unclear. Methods: To asses the effect of preoperative IABP on troponin levels, surgical timing, and postoperative outcomes, 230 AMI patients scheduled for CABG were divided into two groups: Group A received support with IABP, whereas Group B served as the control group without IABP. The analysis evaluated the preoperative reduction in high-sensitivity cardiac troponin I (hsCTI) levels, timing of surgery, durations of intensive care unit (ICU) and hospital stays (HS), and mortality rates. Results: After propensity score matching, Group A comprised 64 patients with a mean age of 63.1 ± 8.9 years, and Group B comprised 92 patients with a mean age of 65.2 ± 8.1 years. In the IABP group, participants exhibited relief from angina symptoms, faster reduction in hsCTI levels, improved transit-time flow measurement (TTFM) of grafts, and shorter ICU and HS durations. The overall mortality rate was 7.1%. However, preoperative IABP support reduced the mortality rate by a factor of 0.6 compared to intraoperative IABP (β = –0.86; Z = –2.41; OR = 0.42, 95% CI: 0.2–0.85; p = 0.016). Conclusions: The IABP provides myocardial preconditioning in patients with AMI, thus preparing the myocardium for CABG. Its use should be considered, particularly for high-risk patients. This study has obtained a clinical registration number (NCT number: NCT06468982).

Outcomes among patients with non-ST-elevation myocardial infarction on chronic anticoagulation: Insights from the National Inpatient Sample.

Chronic systemic anticoagulation use is prevalent for various thromboembolic conditions. Anticoagulation (usually through heparin products) is also recommended for the initial management of non-ST-elevation myocardial infarction (NSTEMI). To evaluate the in-hospital outcomes of patients with NSTEMI who have been on chronic anticoagulation. Using the National Inpatient Sample (NIS) years 2016-2020, NSTEMI patients and patients with chronic anticoagulation were identified using the appropriate International Classification of Diseases, 10th version (ICD-10) appropriate codes. The primary outcome was all-cause in-hospital mortality while the secondary outcomes included major bleeding, ischemic cerebrovascular accident (CVA), early percutaneous coronary intervention (PCI) (i.e., within 24 h of admission), coronary artery bypass graft (CABG) during hospitalization, length of stay (LOS), and total charges. Multivariate logistic or linear regression analyses were performed after adjusting for patient-level and hospital-level factors. Among 2,251,914 adult patients with NSTEMI, 190,540 (8.5%) were on chronic anticoagulation. Chronic anticoagulation use was associated with a lower incidence of in-hospital mortality (adjusted odds ratio [aOR]: 0.69, 95% confidence interval [CI]: 0.65-0.73, p < 0.001). There was no significant difference in major bleeding (aOR: 0.95, 95% CI: 0.88-1.0, p = 0.15) or ischemic CVA (aOR: 0.23, 95% CI: 0.03-1.69, p = 0.15). Chronic anticoagulation use was associated with a lower incidence of early PCI (aOR: 0.78, 95% CI: 0.76-0.80, p < 0.001) and CABG (aOR: 0.43, 95% CI: 0.41-0.45, p < 0.001). Chronic anticoagulation was also associated with decreased LOS and total charges (adjusted mean difference [aMD]: -0.8 days, 95% CI: -0.86 to -0.75, p < 0.001) and (aMD:$-19,340, 95% CI: -20,692 to -17,988, p < 0.001). Among patients admitted with NSTEMI, chronic anticoagulation use was associated with lower in-hospital mortality, LOS, and total charges, with no difference in the incidence of major bleeding.

The impact of ticagrelor therapy on CABG-related bleeding in patients with STEMI managed with pPCI and following on-pump CABG.

Patients on double antiplatelet treatment who need early in-hospital coronary artery bypass grafting (CABG) are at high risk of major bleeding. In this study, we aimed to investigate the impact of ticagrelor preloading on CABG related bleeding in patients with ST-segment elevation myocardial infarction (STEMI) initially managed with primary percutaneous coronary intervention (pPCI). Patients with the diagnosis of STEMI who were managed with pPCI and underwent subsequent early (4-7days following pPCI) or delayed (> 7days following pPCI) on-pump CABG surgery were included. All study patients were preloaded with ticagrelor 180mg prior to pPCI procedure. Patients' demographics, clinical variables, and short-term cardiovascular outcomes were recorded. This is a retrospective study which included 98 patients. Fifty-four (54%) patients underwent early and 44 (45%) patients underwent delayed CABG surgery. CABG-related bleeding occurred in 22 (22.4%) patients. There was no significant difference with respect to total ticagrelor dose and timing of the surgery between patients with or without CABG-related bleeding (p: 0.165 and p: 0.142). Multivariate analyses demonstrated that only preoperative hemoglobin level < 10.9 and use of mechanical cardiac support devices were independent predictors of CABG-related bleeding [OR: 3719, p: 0.009 and OR: 11,698, p: 0.004, respectively].There were three deaths within the 30days of surgery, all occurring in patients with CABG-related bleeding. However, CABG-related bleeding was not associated with long-term cardiovascular events during the follow-up. Our results indicated that discontinuation of ticagrelor therapy 3days prior to surgery is sufficient to avoid CABG-related bleeding. Moreover, early CABG following STEMI does not increase the risk of long-term cardiovascular events.

Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients. Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival. During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival. In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

Should the left internal mammary artery (LIMA) be imaged before radiotherapy in cases of unexpected early acute coronary syndrome?

Abstract Funding Acknowledgements None. Case A 41-year-old male patient presented to the cardiology outpatient clinic with a complaint of exertional chest pain persisting for the past 4 months, along with occasional palpitation attacks. In his medical history, aside from being diagnosed with lymphoma 15 years ago, there were no known additional comorbidities. The electrocardiogram (EKG) revealed sinus rhythm (84 beats/minute), and the blood tests showed creatinine: 0.81 mg/dL, WBC: 11.26 mm^3, LYM: 3.69 mm^3. Transthoracic echocardiography demonstrated an ejection fraction (EF) of 60%, with no additional pathologies except for grade 1 diastolic dysfunction. Considering the presence of typical chest pain, coronary imaging was performed to assess for stable angina. The coronary imaging revealed a lesion extending from the left main coronary artery (LMCA) to the proximal left circumflex artery (CX), with an 80% stenosis in the mid-segment of the LMCA, a 60% stenosis at the narrowest point of the CX proximal segment, and an 80% stenosis in the proximal right coronary artery (RCA). The left circumflex artery obtuse marginal branches (CX OM) appeared thin and extensively diseased (Figure-1) The patient was promptly scheduled for early coronary artery bypass grafting (CABG), transferred to the cardiac surgery intensive care unit, and underwent a successful coronary bypass procedure with LAD-LIMA, Ao-saphenous-IM-saphenous-CxOM1 (sequential) grafting. Throughout the postoperative follow-up period, the patient continued to experience exertional chest pain despite medical treatment. A repeat coronary angiography was performed, revealing that the bypass grafts were opened, but a diffuse 80% stenosis was detected at the mid-segment of the LIMA graft, prior to the anastomosis.(Figure-2) Successful stent placement was performed at the narrowest point of the LIMA mid-segment (Figure-3).The patient had no anginal complaints during post-procedure follow-up and has been stable under observation. Discussion Routine clinical practice does not involve LIMA imaging in patients who have undergone diagnostic coronary angiography with multi-vessel involvement and a CABG decision. However, the use of coronary artery bypass graft surgery (CABG) may entail a risk of rendering the graft unusable due to extensive mediastinal fibrosis and radiation-induced damage to the left or right mammary artery. Therefore, in patients with a history of radiation exposure in the thoracic region and a CABG decision, the visualization of the intermammary artery during coronary angiography and the consideration of alternative grafts, such as the radiation-free radial artery, or the necessity for high-risk percutaneous stent implantation, should be discussed.figure-1figure-2

A comparative assessment of neurochemical and neurophysiological parameters of cardiac surgery patients who underwent different versions of multitasking cognitive training

To compare biomarkers of neurovascular unit (NVU) - S100β, NSE, BDNF and indicators of the brain electrical activity in patients who underwent coronary artery bypass grafting (CABG) depending on the use of different versions of multi-tasking cognitive training (CT). The study included 89 people, of whom 47 completed the CTI (postural and three cognitive tasks (counting backwards, verbal fluency and the open-ended task «Unusual use of an ordinary object») and 42 patients, who underwent CTII (visuomotor reaction and the same cognitive tasks) in the early postoperative CABG period. The patients of both groups underwent complex testing of psychomotor, executive functions, attention, short-term memory and EEG study in the perioperative period of CABG. Concentrations of NVU markers in peripheral blood serum were also analyzed. The highest values of S100β protein concentration in both patients with CTI and CTII were observed on the 1st-2nd days after CABG, followed by a significant decrease on the 10th-12th days to preoperative values only in the CTII group. Also, during CTI, low concentrations of S100β and NSE protein were associated with higher indicators of cognitive status, such as short-term memory and general integral index. In patients with CTI, the concentration of BDNF on days 10-12 of CABG was significantly higher compared to patients with CTII, and its higher levels were associated with higher levels of attention. Only if the training was successful, the patients with CTI had greater preoperative levels of EEG alpha-1 and alpha-2 activity compared to patients with CTII. The version of multitasking CT using the postural motor component more actively triggered the processes of neuroplasticity due to the expression of BDNF and its success was due to the greater presence of alpha-activity in the preoperative period of CABG. Further research is needed to study the neurophysiological mechanisms of recovery of cognitive functions after cardiac surgery.

The impact of ticagrelor therapy on CABG-related bleeding in patients with STEMI managed with pPCI

Abstract Background Patients on double antiplatelet treatment who need early in-hospital coronary artery bypass grafting (CABG) are at high risk of major bleeding. However, recent studies have demonstrated that early CABG surgery within 7 days of discontinuation of p2Y12 inhibitors are safe with respect to bleeding events in patients with acute coronary syndrome. Purpose In this study, we aimed to investigate the impact of ticagrelor preloading on CABG related bleeding in patients with ST-segment elevation myocardial infarction (STEMI) initially managed with primary percutaneous coronary intervention (pPCI). Methods Patients with the diagnosis of STEMI who were managed with pPCI and underwent subsequent early (4-7 days following pPCI) or delayed (&amp;gt; 7 days following pPCI) CABG surgery were included. All study patients were preloaded with ticagrelor 180 mg prior to pPCI procedure. Patients’ demographics, clinical variables and short-term cardiovascular outcomes were recorded. Results The study cohort included 98 patients. Fifty-four (54%) patients underwent early and 44(45%) patients underwent delayed CABG surgery. Left main coronary artery involvement and presence of chronic total occlusion in the non-infarct related artery were 26.5% and 25.5%. CABG-related bleeding occurred in 22 (22.4%) patients. There was no significant difference with respect to total ticagrelor dose and timing of the surgery between patients with or without CABG-related bleeding (p: 0.165 and p:0.142). Multivariate analyses demonstrated that only preoperative hemoglobin level was an independent predictor of CABG-related bleeding (OR:0.720, p: 0.034).There were three deaths within the 30 days of surgery, all occurring in patients with CABG-related bleeding. However, CABG-related bleeding was not associated with long-term cardiovascular events during the follow-up. Conclusion Our results indicated that discontinuation of ticagrelor therapy 3 days prior to surgery is sufficient to avoid CABG-related bleeding. Moreover, early CABG following STEMI does not increase the risk of long-term cardiovascular events.

Effectiveness of Acapella along with institutional based chest physiotherapy techniques on pulmonary functions and airway clearance in post-operative CABG patients.

Patients undergoing Coronary Artery Bypass Graft (CABG) surgery often develop pulmonary complications in the early post-operative period as result of decreased lung function and impaired cough. Conventional physiotherapy in early post-operative period aims at increasing lung volumes and airway clearance. This study aimed to determine the effectiveness of the addition of Acapella to conventional chest physiotherapy in improving lung volumes and secretion clearance in early post-operative CABG patients. Twenty patients of both genders (40-70 years) who had undergone CABG and were in Phase I of Cardiac Rehabilitation were involved in this pilot randomized control trial (9 control, 11 experimental). Post-surgery intervention commenced on post-operative day 2 (POD 2) and continued till POD 6. Patients in the control group were given conventional physiotherapy that included breathing exercises, incentive spirometry and manual techniques. Patient in the experimental group used an Acapella device along with the conventional intervention. Outcome measures considered were pulmonary function parameters (FVC, FEV1 & PEFR) and amount of sputum expectorated. A significant increase in lung volumes was observed in both the groups on POD 6 as compared to POD 2 (). However, the increase was significantly greater on POD 6 in experimental group than the control group [mean difference (95% CI) FVC: 0.44 L (0.24-0.63), FEV1: 0.43 L (0.19-0.66), PEFR: 0.86 L/s (0.57-1.14)]. The amount of sputum expectoration significantly greater in the experimental group as compared to the control group [2.71 mL (0.53-4.90)]. The addition of Acapella enhanced the effect conventional physiotherapy in improving lung volumes and airway clearance in the early post-operative period for CABG patients.

Clinical value of troponin profiles in early post coronary artery bypass grafting acute care in advanced chronic kidney disease patients: An insight into perioperative patient characteristics

Abstract Funding Acknowledgements Type of funding sources: None. Background and Aims Diagnosis of type V myocardial infarction (MI) in patients with advanced chronic kidney disease (CKD) undergoing coronary revascularisation surgery (CAB) presents a clinical challenge. We describe postoperative serum troponin (cTn) trends after CAB in CKD stages IV-V, and assess associations with gender, preoperative dialysis, clinical presentation and CAB method. Methods We analysed 51 patients with CKD stage IV-V who underwent CAB at a single centre between 2016-2021. Data on patient characteristics, CAB surgery, and cTn (T) levels were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Patient characteristics were compared between patients undergoing on-pump vs off-pump CAB using appropriate testing methods. The differences in cTn trends between males vs females, acute coronary syndrome (ACS) vs stable angina, patients undergoing preoperative dialysis vs not, and on-pump vs off-pump CAB at different time points were assessed using repeated measurements, and a p value&amp;lt;0.05 was considered to be statistically significant. Results Among 51 patients with stage IV (47%) and V (53%) CKD, off-pump CAB was conducted in 41% (21) of the patients, while the rest underwent on-pump CAB. Patients in the off-pump group were older (62.2 vs 56.6 years, p=0.03), and there were no other statistically significant differences in patient characteristics between groups (Table). Over time, cTn levels increased from 0.34 [0.08-0.9] ng/mL at 24h preoperatively to achieve a peak of 0.75 [0.44-1.7] ng/mL at 18h postoperatively. When comparing cTn trends according to gender, preoperative dialysis, clinical presentation and CAB method, cTn levels were higher in males, patients presenting with ACS, patients who did not undergo preoperative dialysis, and in the on-pump CAB group (Figure). However, in this small sample size study, between-group differences in cTn trends did not achieve statistical significance (p=0.26, p=0.18, p=0.5, and p=0.28, respectively). Conclusion Serum troponin levels peaked consistently by 18h postoperatively in advanced CKD patients undergoing CAB. In addition, males, ACS, on-pump CAB, and non-preoperatively dialysed patients had higher levels of cTn. Further large scale studies are required to definitively evaluate the diagnostic utility and cTn cut-off in this high-risk population.

Custodiol-HTK Solution Vs. Conventional Cardioplegia for Myocardial Protection During Coronary Artery Bypass Grafting Following Recent ST-Elevation Myocardial Infarction

Abstract Background: Histidine-tryptophan-ketoglutarate (HTK), Bretschneider's, or Custodiol is an intracellular crystalloid cardioplegic solution which is claimed to offer single shot cardioplegia for myocardial protection during complex cardiac procedures for up to 3 h. We aimed to compare the clinical outcome of early coronary artery bypass grafting (CABG) using blood cardioplegia vs. Custodiol solution for myocardial protection in patients with recent ST-elevation myocardial infarction (STEMI). Materials and Methods: This prospective comparative study included 100 patients with recent STEMI who underwent early CABG at our institution between January 2019 and December 2020. The patients were divided into two groups: group A (n = 50) received blood cardioplegia and group B (n = 50) received Custodiol-HTK crystalloid cardioplegia. Results: There were non-significant differences in postoperative mortality and complication rates between both the groups except for significantly higher proportion of post-operative arrythmias after Custodiol cardioplegia (26% vs. 8%, P = 0.01). Custodiol was associated with significantly lower levels of blood troponin and higher levels of blood lactate for 6 h after CABG. Custodiol results in significantly shorter durations of mechanical ventilation (11.98 ± 4.03 vs. 18.28 ± 8.84 h, P &lt; 0.001) and intensive care unit (ICU) stay (70.04 ± 14.80 vs. 80.20 ± 19.91 h, P = 0.01), with non-significantly shorter duration of post-operative hospital stay (7.98 ± 2.76 vs. 9.24 ± 3.41 days, P = 0.06). Conclusion: Custodiol as a single shot without interruption of the operative technique offers shorter durations of mechanical ventilation and ICU stay than blood cardioplegia, with more acceptable levels of post-operative troponin in high-risk patients who underwent early CABG for recent STEMI.

Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study

BackgroundDual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI.MethodsIn this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes.ResultsThe in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9–20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446).ConclusionsA 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.

Graft flow assessment and early coronary artery bypass graft failure: a computed tomography analysis.

OBJECTIVESWe evaluated graft patency by computed tomography and explored the determinants of intraoperative mean graft flow (MGF) and its contribution to predict early graft occlusion.METHODSOne hundred and forty-eight patients under a single surgeon were prospectively enrolled. Arterial and endoscopically harvested venous conduits were used. Intraoperative graft characteristics and flows were collected. Graft patency was blindly evaluated by a follow-up computed tomography at 11.4 weeks (median).RESULTSGraft occlusion rate was 5.2% (n = 22 of 422; 8% venous and 3% arterial). Thirteen were performed on non-significant proximal stenosis while 9 on occluded or >70% stenosed arteries. Arterial and venous graft MGF were lower in females (Parterial = 0.010, Pvenous = 0.009), with median differences of 10 and 13.5 ml/min, respectively. Arterial and venous MGF were associated positively with target vessel diameter ≥1.75 mm (Parterial = 0.025; Pvenous = 0.002) and negatively with pulsatility index (Parterial < 0.001; Pvenous < 0.001). MGF was an independent predictor of graft occlusion, adjusting for EuroSCORE-II, pulsatility index, graft size and graft type (arterial/venous). An MGF cut-off of 26.5 ml/min for arterial (sensitivity 83.3%, specificity 80%) and 36.5 ml/min for venous grafts (sensitivity 75%, specificity 62%) performed well in predicting early graft occlusion.CONCLUSIONSWe demonstrate that MGF absolute values are influenced by coronary size, gender and graft type. Intraoperative MGF of >26.5 ml/min for arterial and >36.5 ml/min for venous grafts is the most reliable independent predictor of early graft patency. Modern-era coronary artery bypass graft is associated with low early graft failure rates when transit time flow measurement is used to provide effective intraoperative quality assurance.

TCTAP C-027 Early Coronary Artery Bypass Graft (CABG) Failure in High SYNTAX Score: What’s Next?

TCTAP C-027 Early Coronary Artery Bypass Graft (CABG) Failure in High SYNTAX Score: What’s Next?

Early-term results of early coronary artery bypass graft surgery in patients undergoing primary percutaneous coronary intervention due to acute coronary syndrome

Objectives: This study aimed to investigate the early results of the patients presented with acute coronary syndrome (ACS) who underwent coronary artery bypass grafting (CABG) after percutaneous coronary intervention (PCI) to the culprit lesion. Methods: Patients who underwent CABG between January 2011 and January 2014 were enrolled and divided into two groups. Group 1 (102 patients) was consist of the patients who were hospitalized with ACS and underwent CABG after a previous PCI. Group 2 (107 patients) was consisting of the patients who underwent elective CABG operation after elective coronary angiography. Results: There was no statistically significant difference between the groups in terms of demographic features and preoperative risk factors. Preoperative use of angiotensin-converting enzyme inhibitor and levosimendan were significantly higher in group 1 compared to group 2. (95 (93.1%) vs. 89 (83.1%), p = 0.027). The operative variables were similar between two groups whereas the postoperative blood drainage amounts were significantly higher in group 1 than group 2 (546.3 ± 172 cc vs. 424.2 ± 185 cc, respectively, p &amp;lt; 0.001). The blood product usage was significantly higher in group 1 than in group 2 (3.3 ± 1.8 units vs.1.7 ± 0.9 units, respectively, p &amp;lt; 0.001). Conclusions: Early CABG operation after ACS is a safely applicable process with acceptable mortality and complication rates.

Impact of Delay in Surgery on Outcome in Patients Undergoing Cardiac Revascularisation Surgery

Diagnosis of critical coronary artery disease, including after acute coronary syndrome presentation (ACS), represents an important indication for early coronary artery bypass graft (CABG) surgery. The study aims to investigate the influence of time from diagnosis to CABG on outcomes and document barriers to early revascularisation. All patients 18 years and older with an acute presentation due to ACS or critical coronary artery disease who were considered to require urgent inpatient cardiac surgery between January 2016-February 2019 were included in the study. The primary endpoints were 30-day all-cause mortality or readmission, 1-year all-cause mortality, all-cause readmission. The secondary endpoint was the rate of complications while waiting for surgery. The time duration between diagnostic coronary angiography and surgery was considered as the time interval. Of 266 eligible patients, 251 underwent surgical revascularisation with 15 (6%) not undergoing surgery due to preoperative complications (n=12) or due to perceived prohibitively high surgical risk (n=3). The majority (85%) were male (mean age 67 years), 37% of patients had diabetes and 71% had hypertension. Non-ST elevation myocardial infarction was documented in 51% of the patients. The median time between diagnosis and inpatient CABG was 7 days (IQR 5-11). Thirty-five per cent (35%) of patients experienced complications while awaiting surgery. Of the 266 patients, 140 patients (53% - cohort 1) underwent surgery within 7 days. The cohort 1 rate of complications was lower than in cohort 2 (surgery after 7 days) (24 vs 47%, p<0.001). Moreover, 1-year mortality was less in cohort 1 (2 vs 8%, p=0.029). In patients requiring urgent inpatient CABG, delay for more than 7 days is associated with a higher rate of in-hospital complications and worse 30 day and 12-month outcomes.

Outcomes of coronary artery bypass grafting in patients with high-risk non-ST-segment elevation acute coronary syndrome within the first 24 hours of admission

Aim. The current myocardial re-vascularisation guidelines recommend that the coronary re-vascularisation of patients with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) should be performed within 24 hours of admission. In real clinical practice; however, it is not always possible to keep coronary bypass surgery on schedule owing to various reasons. The aim of the current study, which presents cases of successful adherence to the surgical schedule, was to explore the need for 24/7 cardiac surgery services and to evaluate the outcomes of early (i.e. during the first 24 hours) coronary artery bypass grafting in 21 patients with high-risk NSTE-ACSs.Methods. The medical records of patients undergone coronary bypass surgery for high-risk NSTE-ACSs within the first 24 hours of admission between 2017 and 2019 were retrospectively analysed.Results. The mean age of the patients was 64.3 ± 5.6 years. Myocardial infarction was confirmed in 52.4 % (n = 11) of the subjects and progressive angina pectoris in 47.6 % (n = 10). The average waiting time to surgery was 17.8 ± 4.7 hours. Besides, 9.5 % (n = 2) of the cases, who had received dual antiplatelet therapy, exhibited a shorter waiting time to surgery. Patients were characterised by extremely severe clinical and angiographic status as follows: one in three had post-infarction cardiosclerosis and a first-degree family history of obesity; one in four had a history of percutaneous coronary intervention; and 61.9 % (n = 13) were found to have a left main coronary artery lesion, in 79.6 % (n = 10) of whom the left main coronary artery stenosis appeared to be greater than 80 %, necessitating the intra-aortic balloon counter-pulsation therapy in 33.3 % (n = 7) overall. Also, the mean cardiopulmonary bypass time turned out to be 88.6 ± 27.1 minutes, with an aortic clamping time of 47.6 ± 14.7 minutes. The in-hospital mortality rate was 14.3 % (n = 3), with cardiac and respiratory failure as well as mediastinitis (in one patient) being among the causes of adverse outcomes. So far, none of the studied cases has required re-sternotomy due to bleeding or perioperative acute cerebrovascular accident.Conclusion. In high-risk NSTE-ACS patients with severe clinical and angiographic status, emergency coronary bypass surgery performed within 24 hours of admission may prove an effective treatment option that can help save patients’ lives through complete re-vascularisation.Received 31 March 2020. Revised 2 May2020. Accepted 16 May 2020. Funding: The study is supported as a part of the research program "Complete myocardial revascularization in patients with non-ST segment elevation acute coronary syndrome with coronary artery bypass grafting". Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and design: A.B. NishonovData collection and analysis: A.B. NishonovDrafting the article: A.B. Nishonov, R.S. TarasovCritical revision of the article: S.V. Ivanov, T.S. Golovina, L.S. BarbarashFinal approval of the version to be published: A.B. Nishonov, R.S. Tarasov, S.V. Ivanov, T.S. Golovina, L.S. Barbarash

Percutaneous or surgical revascularization is associated with survival benefit in stable coronary artery disease.

We assessed the association between early invasive therapy, burden of ischaemia, and survival benefit separately for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Ischaemia involving more than 10% of the left ventricular myocardium may identify patients who benefit from revascularization. However, it is not clear whether this association exists with both PCI and CABG. Patients who underwent single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) between 1992 and 2012 were identified. Early revascularization was defined as PCI or CABG performed within 90 days of SPECT MPI. The association between early PCI or CABG and all-cause mortality was assessed using a doubly robust, propensity score matching analysis. In total, 54 522 patients were identified, with median follow-up 8.0 years. Early PCI was performed in 2688 patients and early CABG in 1228. In the matched cohorts, early revascularization was associated with improved survival compared to medical therapy in patients with more than 15% ischaemia for both PCI [adjusted hazard ratio (HR) 0.70, P = 0.002] and CABG (adjusted HR 0.73, P = 0.008). In this observational analysis, both PCI and CABG were associated with reduced all-cause mortality in the presence of moderate to severe ischaemia after adjusting for factors leading to revascularization. As the threshold for improved outcomes with revascularization was similar for PCI and CABG, our results suggest that decisions for PCI vs. CABG for early revascularization should be determined by coronary anatomy, patient characteristics, and shared decision making, but not by the burden of ischaemia.

Early surgical myocardial revascularization in non-ST-segment elevation acute coronary syndrome.

In non-ST-elevation myocardial infarction (NSTEMI) there is no consensus regarding optimal time point for coronary artery bypass grafting (CABG). Recent findings suggest that long-term outcomes are improved in early-revascularized NSTEMI patients. However, it has been stated that early surgery is associated to increased operative risk. In this study, we wanted to elucidate if early CABG in non-ST-elevation acute coronary syndrome can be performed safely. We performed a monocentric-prospective observational study within a 2-year interval. A total of 217 consecutive patients (41 female, age 68.9±10.2, ES II 6.62±8.56) developed NSTEMI and underwent CABG. Patients were divided into two groups according to the time point of coronary artery bypass after symptom onset (group A: <72 h; group B: >72 h). Endpoints included 6-month mortality and incidence of MACE (death, stroke or re-infarction). There were no differences regarding mortality between both groups (30 days: group A 2.4% vs. group B 3.7%; P=0.592; 6 months: 8.4% vs. 6.0%; P=0.487). Incidence of MACE in the 6-month follow-up was also similar in both groups (group A: 9.6% vs. 9.7%, P=0.982). Regression analysis revealed as independent risk factors for mortality in the entire cohort ES II OR 1.045 (95% CI: 1.004-1.088). ES II remained an independent prognostic factor in group A OR 1.043 (95% CI: 1.003-1.086) and group B OR 1.032 (95% CI: 1.001-1.063). Early revascularized patients showed a higher level of illness. However, results of early CABG were comparable to those following delayed revascularization. Moreover, EuroSCORE II was determined as independent risk factors for mortality.

Stable Ischemic Heart Disease: Medical Therapy With or Without Revascularization

Coronary artery disease (CAD) poses a significant global public health burden. Patients with CAD who do not present with acute coronary syndromes are considered to have stable ischemic heart disease (SIHD). Options for the management of SIHD are medical therapy including pharmacologic therapy and lifestyle modification and revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Guideline-directed medical therapy is recommended for all patients with SIHD. Aside from severe stenosis in an unprotected left main coronary artery, the role of routine revascularization in the management of SIHD is unclear. Early CABG trials from the 1970s and 1980s demonstrated prognostic benefit with CABG versus medical therapy, but these results have limited applicability in the setting of modern medical therapy, including the widespread use of statins and aspirin and intensive lifestyle interventions. Contemporary strategy trials examining PCI plus medical therapy versus medical therapy alone have not demonstrated prognostic benefit with the addition of PCI. The addition of revascularization offers consistent symptom and quality-of-life benefit compared with medical therapy alone based on trial data, though this benefit may be time limited with PCI. Thus, there is a state of equipoise regarding the addition of revascularization to guideline-directed medical therapy in the management of SIHD. Therefore, shared decision-making is key when determining the best management strategy for a patient with SIHD and should include discussion of expected risks and benefits based on high-quality evidence, costs, and patient preferences. This review contains 6 figures, 8 tables, and 55 references. Key Words: angina, antianginal therapy, coronary artery disease, coronary artery bypass grafting, guideline-directed medical therapy, ischemia, optimal medical therapy, percutaneous coronary intervention, revascularization

Postoperative interleukin-8 levels are related to the duration of coronary artery bypass grafting surgery and predict in-hospital postsurgical complications

Abstract Introduction: The magnitude of the very early coronary artery bypass grafting (CABG)-related inflammatory response has been shown to influence post-CABG outcomes. However, the dynamics of the systemic inflammatory response to CABG beyond the very early postoperative phase and its relevance to clinical outcomes are not fully understood. Methods: Circulating levels of several inflammatory markers were determined in 30 consecutive patients undergoing elective isolated on-pump CABG one day prior (D0-1), and 2 (D2) and 5 days post-CABG. Results: CABG was associated with a significant increase in all studied inflammatory marker levels (all p&lt;0.05 for D2 versus D0-1). D2 post-CABG IL-6 and IL-8 levels were both significantly positively correlated with extracorporeal circulation (ECC) and aortic clamping (AC) times (all p&lt;0.05), whereas a weaker correlation was observed between D2 post-CABG IL-8 levels and total surgery time (r=0.42, p=0.02). In multiple regression analysis, D2 IL-8 levels independently predicted post-CABG kidney (p= 0.02) and liver (p = 0.04) dysfunction, as well as a sum of post-CABG major complications ≥2 (p = 0.04). Conclusions: In this prospective study, longer duration of cardiopulmonary bypass caused a larger post-CABG inflammatory surge, whereas the duration of total CABG surgery had a less significant effect. IL-8 hyperresponders had greater risk of developing kidney and liver dysfunction and presented more major post-CABG complications. These data suggest that targeting the IL-8 pathway using antiinflammatory agents, or simply by shortening the duration of cardiopulmonary bypass could improve the in-hospital post-CABG outcomes in this population.