Emergency Coronary Artery Bypass Surgery Research Articles

Emergency coronary artery bypass surgery after chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BackgroundEmergency coronary artery bypass surgery (eCABG) is a serious complication of chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI). MethodsWe examined the incidence and outcomes eCABG among 14,512 CTO PCIs performed between 2012 and 2023 in a large multicenter registry. ResultsThe incidence of eCABG was 0.12% (n = 17). Mean age was 68 ± 6 years and 69% of the patients were men. The most common reason for eCABG was coronary perforation (70.6%). eCABG patients had larger target vessel diameter (3.36 ± 0.50 vs. 2.90 ± 0.52; p = 0.003), were more likely to have moderate/severe calcification (85.7% vs. 45.8%; p = 0.006), side branch at the proximal cap (91.7% vs. 55.4%; p = 0.025), and balloon undilatable lesions (50% vs. 7.4%; p = 0.001) and to have undergone retrograde crossing (64.7% vs. 30.8%, p = 0.006). eCABG cases had lower technical (35.3% vs. 86.7%; p < 0.001) and procedural (35.3% vs. 86.7%; p < 0.001) success and higher in-hospital mortality (35.3% vs. 0.4%; p < 0.001), coronary perforation (70.6% vs. 4.6%; p < 0.001), pericardiocentesis (47.1% vs. 0.8%; p < 0.001), and major bleeding (11.8% vs. 0.5%; p < 0.001). ConclusionsThe incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality (35%). Coronary perforation was the most common reason for eCABG.

Association of the COVID-19 Pandemic on Treatment Times for ST-Elevation Myocardial Infarction: Observations from the Los Angeles County Regional System

Previous studies have documented longer treatment times and worse outcomes for patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic. The objective of the present study was to evaluate the impact of the COVID-19 pandemic on treatment times and outcomes for patients with STEMI who underwent primary PCI within a regional system of care. This was a retrospective study using data from the Los Angeles County Emergency Medical Services Agency. Data on the emergency medical service activations were abstracted for patients with STEMI from March 19, 2020 to January 31, 2021, during the COVID-19 pandemic and for the same interval the previous year. All adult patients (≥18years) with STEMI who underwent emergent coronary angiography were included. The primary end point was the first medical contact (FMC) to device time. The secondary end points included treatment time intervals, vascular complications, need for emergent coronary artery bypass surgery, length of hospital stay, and in-hospital mortality. During the study period, 3,017 patients underwent coronary angiography for STEMI, 1,893 patients pre-COVID-19 and 1,124 patients during COVID-19 (40% lower). A total of 2,334 patients (77%) underwent PCI. During the COVID-19 period, rates of PCI were significantly lower compared with the control period (75.1% vs 78.7%, p=0.02). FMC to device time was shorter during the COVID-19 period compared with the control period (median 77.0 vs 81.0minutes, p=0.004). For patients with STEMI complicated by out-of-hospital cardiac arrest, FMC to device time was similar during the COVID-19 period compared with the control period (median 95.0 [33.0] vs 100.0 [40.0]minutes, p=0.34). Vascular complications, the need for emergent bypass surgery, length of hospital stay, and in-hospital mortality were similar between the periods. In conclusion, in this large regional system of care, we found a relatively small but significant decrease in treatment times, yet overall, similar clinical outcomes for patients with STEMI who underwent primary PCI and were treated during the COVID-19 period compared with a control period. These findings suggest that mature cardiac systems of care were able to maintain efficient care despite the challenges of the COVID-19 pandemic.

First myocardial infarction in patients with premature coronary artery disease: insights into patient characteristics and outcome after treatment with contemporary stents.

Patients with premature coronary artery disease (CAD) have a higher incidence of myocardial infarction (MI) than patients with non-premature CAD. The aim of the present study is to asess differences in clinical outcome after a first acute MI, percutaneously treated with new-generation drug-eluting stents between patients with premature and non-premature CAD. We pooled and analysed the characteristics and clinical outcome of all patients with a first MI (and no previous coronary revascularization) at time of enrolment, in four large-scale drug-eluting stent trials. Coronary artery disease was classified premature in men aged <50 and women <55 years. Myocardial infarction patients with premature and non-premature CAD were compared. The main endpoint was major adverse cardiac events (MACE): all-cause mortality, any MI, emergent coronary artery bypass surgery, or clinically indicated target lesion revascularization. Of 3323 patients with a first MI, 582 (17.5%) had premature CAD. These patients had lower risk profiles and underwent less complex interventional procedures than patients with non-premature CAD. At 30-day follow-up, the rates of MACE [hazard ratio (HR): 0.22, 95% confidence interval (CI): 0.07-0.71; P = 0.005), MI (HR: 0.22, 95% CI: 0.05-0.89; P = 0.020), and target vessel failure (HR: 0.30, 95% CI: 0.11-0.82; P = 0.012) were lower in patients with premature CAD. At 1 year, premature CAD was independently associated with lower rates of MACE (adjusted HR: 0.50, 95% CI: 0.26-0.96; P = 0.037) and all-cause mortality (adjusted HR: 0.24, 95% CI: 0.06-0.98; P = 0.046). At 2 years, premature CAD was independently associated with lower mortality (adjusted HR: 0.16, 95% CI: 0.05-0.50; P = 0.002). First MI patients with premature CAD, treated with contemporary stents, showed lower rates of MACE and all-cause mortality than patients with non-premature CAD, which is most likely related to differences in cardiovascular risk profile. TWENTE trials: TWENTE I, clinicaltrials.gov: NCT01066650), DUTCH PEERS (TWENTE II, NCT01331707), BIO-RESORT (TWENTE III, NCT01674803), and BIONYX (TWENTE IV, NCT02508714).

Emergency coronary artery bypass surgery in octogenarians with acute coronary syndrome: off and on pump.

The risk of operation in cardiac surgery increases logarithmically with advanced age. In older individuals, additional comorbidities compel the clinician to deal with postoperative complications. The mortality and morbidity rates of emergency coronary artery bypass surgery (CABG) in the presence of acute coronary syndrome (ACS), or just after it, are higher than those of elective surgeries. In our study, we compared the outcomes of off-pump coronary bypass (OPCAB) and on-pump coronary bypass surgery (ONCAB) in this high-risk subgroup. 383 octogenarians who underwent isolated emergency CABG due to ACS were divided into two groups according to the coronary bypass technique. Group 1 (off-pump) median age (IQR) 84 years (min: 80-max: 99, n = 130); Group 2, (on-pump) median age 85 years (min: 80-max: 89, n=253). Preoperative, intraoperative, and postoperative data were collected retrospectively on standard variables. OPCAB and ONCAB outcomes were compared. ONCAB patients had a significantly longer intensive care unit stay, longer hospital stay, more transfused erythrocyte suspension, more low cardiac output syndrome and acidosis, a higher rate of acute renal failure and a higher rate of stroke than OPCAB patients (respectively; p=0.003; p=0.008; p=0.002; p=0.031; p=0.038, p=0.022, respectively). We showed that emergency OPCAB as a revascularization option in elderly patients with acute coronary syndrome is more advantageous in terms of preventing major postoperative complications.

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

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

Risk of bleeding after percutaneous coronary intervention and its impact on further adverse events in clinical trial participants with comorbid peripheral arterial disease

BackgroundBoth patients with obstructive coronary artery disease (CAD) and patients with peripheral arterial disease (PADs) have an increased bleeding risk. Information is scarce on bleeding in CAD patients, treated with percutaneous coronary intervention (PCI), who have comorbid PADs. We assessed whether PCI patients with PADs have a higher bleeding risk than PCI patients without PADs. Furthermore, in PCI patients with PADs we evaluated the extent by which bleeding increased the risk of further adverse events. MethodsThree-year pooled patient-level data of two randomized PCI trials (BIO-RESORT, BIONYX) with drug-eluting stents were analyzed to assess mortality and the composite endpoint major adverse cardiac events (MACE: all-cause mortality, any myocardial infarction, emergent coronary artery bypass surgery, or target lesion revascularization). ResultsAmong 5989 all-comer patients, followed for 3 years, bleeding occurred in 7.7% (34/440) with comorbid PADs and 5.0% (279/5549) without PADs (HR: 1.59, 95%CI: 1.11–2.23, p = 0.010). Of all PADs patients, those with a bleeding had significantly higher rates of all-cause mortality (HR: 4.70, 95%CI: 2.37–9.33, p < 0.001) and MACE (HR: 2.39, 95%CI: 1.23–4.31, p = 0.003). Furthermore, PADs patients with a bleeding were older (74.4 ± 6.9 vs. 67.4 ± 9.5, p < 0.001). After correction for age and other potential confounders, bleeding remained independently associated with all-cause mortality (adj.HR: 2.97, 95%CI: 1.37–6.43, p = 0.006) while the relation of bleeding with MACE became borderline non-significant (adj.HR: 1.85, 95%CI: 0.97–3.55, p = 0.06). ConclusionPCI patients with PADs had a higher bleeding risk than PCI patients without PADs. In PADs patients, bleeding was associated with all-cause mortality, even after adjustment for potential confounders.

One-Year Outcome of Postoperative Stroke and Nerve Injury After Supraclavicular Revascularization of The Left Subclavian Artery for Proximal Landing Zone Extension in Thoracic Endovascular Aortic Repair

To assess the outcome of stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR). Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between January 2010 and June 2019. Endpoints were perioperative cerebrovascular events and nerve injuries, patency and re-intervention due to the debranching, and mortality at 30 days and during follow-up. Forty-eight patients (median age 66 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%) patients, 11 (23%) of them in an emergent setting. There were 7 (15%) re-interventions within 30 days: 3 due to local hematoma, one for bypass occlusion, 2 for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. 30-day mortality was 2%; 1 patient died on the first postoperative day after emergency coronary artery bypass surgery and multiorgan failure. 4 (8%) patients suffered postoperative strokes; 3 occurred after simultaneous emergency procedures and none was fatal. There were 9 (19%) left neck nerve injuries in 8 patients, 5 patients had SCT and 3 CSB. During a median follow-up of 37.5 months (IQR 23-83) with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 90% and primary assisted patency 98% during follow-up. 8 patients died during follow-up, all of them with patent cervical debranching. Supraclavicular LSA revascularization for proximal landing zone extension in TEVAR is safe with an acceptable rate of early re-interventions. There is higher risk for perioperative stroke during concomitant emergency LSA revascularization and TEVAR. Left neck nerve injuries are common complications but resolve completely in vast majority of the cases during first postoperative year. During follow-up, excellent patency could be expected.

Abstract 12972: Acute Left Main Coronary Artery Thrombosis During Exercise Testing

Background: Exercise stress testing (EST) is safe and effective in evaluating suspected coronary artery disease (CAD). Serious complications are rare. We present a unique case of acute left main coronary artery (LMCA) thrombosis during EST. Case presentation: A 58-year old man with hypertension and hyperlipidemia presented with two episodes of substernal chest pressure within 2 weeks. He had no known CAD, led an active lifestyle and did not smoke, drink, or use drugs. Initial vital signs, routine labs, troponin, ECG, and echocardiogram (TTE) were normal. EST (Bruce Protocol) was terminated at 3’ 54” due to chest pain, hypotension and down-sloping ST segment depressions in inferolateral leads followed by ST segment elevation in leads V1, V2, aVL and aVR. TTE showed severe hypokinesis of apex and anterior, anteroseptal, and anterolateral walls. Emergent coronary angiography (Figure) revealed complete thrombotic occlusion of LMCA. LMCA was wired and ballooned restoring antegrade flow and resolving ST segment elevation. Minutes later, recurrent ST elevations were noted due to LMCA reocclusion. Flow was restored and patient underwent emergent coronary artery bypass surgery. TTE two days later showed preserved LV systolic function with mild hypokinesis of the LV apex and apical septal wall. Conclusions: Pathophysiology of AMI triggered by exercise is only partially understood. Vigorous exercise is shown to increase relative risk of AMI particularly within first hour following exertion. In such a scenario, exercise likely acts as a trigger for plaque rupture in presence of an underlying vulnerable atherosclerotic lesion. Compared to other forms of AMI, those triggered by exercise occur more commonly in men and are more often characterized by total thrombotic occlusion of culprit coronary artery. To our knowledge, acute thrombosis of LMCA has not previously been reported as a complication of EST.

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

Incidence, Characteristics, and Outcomes of Emergent Isolated Coronary Artery Bypass Grafting

Data on emergency coronary artery bypass surgery (CABG) are limited. We studied patients who underwent isolated CABG at Mayo Clinic between 1993 and 2019. Baseline characteristics and in-hospital outcomes of emergent CABG were described in consecutive eras (1993 to 2000, 2001 to 2010, and 2011 to 2019). Cumulative survival was estimated by the Kaplan Meier method for the overall group, and stratified by the indication of surgery. In the 14,455 isolated CABG included, 427 (2.95%) were emergent. The number of emergent CABG decreased from 222 to 150 and 55 in the consecutive study eras. There was a temporal increase in the prevalence of heart failure, but no change in mean age, and prevalence of hypertension, diabetes, renal failure, or atrial fibrillation. The proportion of patients with failed/complicated percutaneous coronary intervention decreased from 38.2% in 1993 to 2000 to 22.7% in 2001 to 2010 and 25.5% in 2011 to 2019 (p = 0.003). In 2011 to 2019, 100% of patient received an internal mammary graft compared with 75.6% in 1993 to 2000 (p < 0.001). Operative mortality was 8.7% overall (8.6% in 1993 to 2000, 10.0% in 2001 to 2010, and 5.5% in 2011 to 2019, p = 0.56). There were no differences in postoperative complications except for the incidence of renal failure and new dialysis which increased over time. Predicted 10-year survival was 57.0% and was not different according to CABG indication (p = 0.12). In conclusion, we documented a temporal decrease in the incidence of emergent CABG between 1993 and 2019, especially those performed due to complications of coronary interventions. Despite the higher prevalence of left ventricular dysfunction and the more complete revascularization in more recent years, in-hospital mortality did not increase.

Hapsedilmiş Yan Dal Telinin Geri Çekilmesi Sırasında İmplante Edilmiş Stentin Yerinden Ayrılması: Sıradışı Bir Komplikasyon

Coronary stent dislodgement is a very rare complication during the percutaneous coronary intervention. It is associated with significant morbidity, systemic or coronary embolization, acute myocardial infarction, emergency coronary artery bypass surgery, vascular access complications, cerebrovascular complications and death. A deployed stent dislodgement is even more rare. We report an unusual complication of a deployed stent dislodgement during retrieval of stent jailed side branch guidewire and retrieval from popliteal artery via snare method. Stent dislodgements usually occur with undeployed stents while retraction of the stent into the guiding catheter .Risk factors for stent loss and dislodgement are severe calcification, tortuosity, failed stent retraction into the guiding catheter and failure to cross the lesion. Stent dislodgement can be treated either surgically or percutaneously

Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: A systematic review and pooled analysis of data.

This review aims to evaluate the adverse outcomes for patients after treatment with covered stents. Coronary perforation is a potentially fatal complication of percutaneous coronary revascularization which may be treated using covered stents. Studies have evaluated long-term outcomes among patients who received these devices, but hitherto no literature review has taken place. We conducted a systematic review of adverse outcomes for patients after treatment with covered stents. Data from studies were pooled and outcomes were compared according to stent type. A total of 29 studies were analyzed with data from 725 patients who received covered stents. The proportion of patients with chronic total occlusions, vein graft percutaneous coronary intervention (PCI), intracoronary imaging and rotational atherectomy were 16.9, 11.5, 9.2, and 6.6%, respectively. The stents used were primarily polytetrafluoroethylene (PTFE) (70%) and Papyrus (20.6%). Mortality, major adverse cardiovascular events, pericardiocentesis/tamponade and emergency surgery were 17.2, 35.3, 27.1, and 5.3%, respectively. Stratified analysis by use of PTFE, Papyrus and pericardial stents, suggested no difference in mortality (p = .323), or target lesion revascularization (p = .484). Stent thrombosis, pericardiocentesis/tamponade and emergency coronary artery bypass surgery (CABG) occurred more frequently in patients with PTFE stent use (p = .011, p = .005, p = .012, respectively). In-stent restenosis was more common with pericardial stent use (<.001, pooled analysis for first- and second-generation pericardial stents). Cases of coronary perforation which require implantation of a covered stent are associated with a high rate of adverse outcomes. The use of PTFE covered stents appears to be associated with more stent thrombosis, pericardiocentesis/tamponade, and emergency CABG when compared to Papyrus or pericardial stents.

Dissection of ascending aorta and left main coronary artery after routine percutaneous coronary intervention: a case report

We describe a case of guiding catheter induced dissection of left main coronary artery and ascending aorta. A patient with unstable angina and two-vessel disease underwent drug eluting stents implantation in proximal left anterior descending artery and distal left circumflex artery. Six hours after the procedure of acute occlusive dissection of left main coronary artery with spreading to ascending aorta developed, it was required to do stenting of the left anterior descending and left main coronary arteries and balloon dilatation of left circumflex artery. Despite the initial success of the repeated intervention, total occlusion of left main coronary artery occurred with unsuccessful reopening in catheterization laboratory. Emergency coronary artery bypass surgery was carried out. However, despite the patent anastomosis from left mammary to left anterior descending artery, the patient died.

Combined pulmonary and left ventricular support with veno-pulmonary ECMO and impella 5.0 for cardiogenic shock after coronary surgery

BackgroundMechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery.Case PresentationWe describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years—old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles.He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up.ConclusionsThe combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.

Is Left Atrial Size a Predictor of Mortality after Coronary Artery Bypass Surgery? A Single Center Study.

To investigate the left atrial (LA) size as an independent predictor of mortality following coronary artery bypass surgery (CABG). This single center study evaluated determinants of mortality in 1070 patients who underwent isolated CABG from 2005-2014. Clinical, laboratory and demographic data were obtained from medical records. Collinearity between enlarged LA size (diameter ≥ 4 cm) and covariates was identified. The adjusted effects of enlarged LA size on 30-day mortality post CABG were tested using multiple logistic regression models. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported. The mean age was 59 ± 9.8 years, and 238 patients were female. Two multivariate logistic regression models were evaluated. In Model A, mitral regurgitation (MR), ejection fraction, intensive care unit length-of-stay and variables found to be collinear with LA size as predictors of mortality were excluded. In model B, the collinear variables were included. By multivariate analysis (Model A), the statistically significant independent predictors of 30-day mortality after CABG were: enlarged LA size (OR 4.82, 95% CI 2.16-10.79), emergency CABG (OR 3.54, 95% CI 1.75-7.18), prolonged inotropic support (OR 2.79, 95% CI 1.38-5.6), diuretic use ≥ 1 month (OR 1.29, 95% CI 1.3-8.42), and use of clopidogrel within a week before surgery (OR 3.27, 95% CI 1.28-8.36. In Model B, enlarged LA and moderate MR were identified as independent predictors of 30-day mortality. Increased LA size is a strong independent predictor of mortality after isolated CABG.

Coronary occlusion after the Manouguian procedure in a patient with a single coronary artery: a case report

BackgroundThe association between the anatomy of a single coronary artery (SCA) and the surgical risk of aortic valve replacement (AVR) remains unclear due to a lack of studies on this topic.Case presentationA 73-year-old woman underwent AVR for aortic stenosis. Preoperative coronary angiography results showed a SCA arising from the left coronary sinus. The Manouguian procedure was performed for a small aortic annulus. Intraoperatively, an extracorporeal membrane oxygenator (ECMO) was needed for bypass weaning failure due to newly developed right ventricular dysfunction. Coronary angiography was performed on postoperative day 4, and the findings showed a right coronary artery occlusion just after its origin. After emergent coronary artery bypass surgery, she could be weaned from the ECMO. She was discharged on postoperative day 70 and followed up without complications for 12 months.ConclusionsAVR with the annular enlargement procedure in those with a SCA can result in an unexpected coronary artery occlusion, which should be, therefore, suspected when unexplained myocardial dysfunction occur. For reducing this risk, the use of a small prosthesis should be considered over the annular enlargement procedure when performing AVR in those with a small aortic annulus and a SCA.Electronic supplementary materialThe online version of this article (doi:10.1186/s13019-016-0542-8) contains supplementary material, which is available to authorized users.

Hand Made Covered Coronary Stent Seals type 3 Coronary Perforation–A Life Saving Procedure When Ready to use Covered Stents are Unavailable

Coronary perforations are classified as type 1- extra luminal crater, type 2-myocardial or pericardial blushing, and type 3-contrast streaming or cavity spilling. Type 3 coronary perforations are associated with high mortality. 1 Treatment modalities of Type 3 coronary perforations include prolonged balloon inflation, pericardiocentesis for cardiac tamponade, coronary artery bypass surgery, and micro coil embolization . A new technique, widely practised, consists of deploying one or more ready to use covered coronary stents to seal the perforation. This has reduced the need for emergency Coronary artery bypass surgery. The author describes here a case of coronary perforation Type 3 occurring unexpectedly after deploying a drug eluting stent across a simple mid left anterior descending artery lesion combined with a situation of non-availability of ready-to-use covered coronary stent in the catheterisation laboratory. A innovative technique of making by hand a covered coronary stent using readily available coronary balloon to cover an appropriately sized coronary stent is described. This handmade covered stent was deployed to seal the coronary perforation successfully and was life saving. Key words : Hand Made Covered Coronary Stent, Coronary Perforation, Non-St-Elevation Myocardial Infarction

Ostial Left Main Coronary Artery Stenosis Mimics Catheter-Induced Vasospasm: A Case of Emergency Coronary Artery Bypass Surgery

Ostial Left Main Coronary Artery Stenosis Mimics Catheter-Induced Vasospasm: A Case of Emergency Coronary Artery Bypass Surgery

Collaborative quality improvement vs public reporting for percutaneous coronary intervention: A comparison of percutaneous coronary intervention in New York vs Michigan

Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR. Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes. Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio [OR] 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001). Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.

Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non-ST-Segment-Elevation Myocardial Infarction?

Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non-ST-segment-elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non-ST-segment-elevation myocardial infarction. A total of 758 patients underwent CABG within 21 days after non-ST-segment-elevation myocardial infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, <24 hours (133 patients); group B, 24 to 72 hours (192 patients); and group C, >72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients): 6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004; and hazard ratio, 1.5; P=0.02), whereas administration of P2Y12 inhibitors was protective (odds ratio, 0.3; P=0.01). Emergent CABG within 24 hours of non-ST-segment-elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early and late death.