Incomplete Surgical Revascularization Research Articles

Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease.

ObjectivesAlthough endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.MethodsWe analyzed patients’ data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.ResultsMedian follow-up was 4.7 years [interquartile range (IQR) 2.3–6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + –0.6 vs. 1.7 + –0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46–3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59–1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71–0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.ConclusionComplete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

Single-territory incomplete surgical revascularization improves regional wall motion of remote ventricular areas: results from a propensity-matched study.

ObjectiveBasic science studies demonstrated a general intramyocardial angiogenetic response potentially responsible for the creation of a microvascular neocapillaries network assisting myocardial function. We hypothesized that the benefit provided by the reperfusion of left anterior descending (LAD) territories and the biological angiogenetic drive triggered by the revascularization could translate in a global improvement in ventricular contractility, not restricted to the grafted area.MethodsHigh-risk patients with multivessel coronary artery disease and preoperative wall motion abnormalities were retrospectively analyzed to compare outcomes and regional ventricular function of those who received optimal medical therapy (OMT) versus those who underwent off-pump coronary artery bypass grafting (OPCABG) and received an incomplete myocardial revascularization using left internal mammary artery (LIMA) on LAD (OPCABG group). From January 2007 to December 2014, 206 patients (OMT, n = 136, OPCABG, n = 70) were propensity-score matched to have 70 matched pairs. Variables included in propensity score analyses were ejection fraction (EF), left ventricular end diastolic volume (LVEDVi), EuroSCORE II. Primary endpoint was the variation in the global wall motion score index (ΔWMSI) as evaluated by transthoracic echocardiography. Follow up was completed at 3 years from surgery or hospital discharge.ResultsRegional analysis of ventricular function revealed a regional WMSI improvement in the OPCABG group not only for LAD territories but also for non-LAD regions, associated with a reduction in the negative left ventricular ischemic remodeling, compared to patients discharged in optimal medical therapy. Global ΔWMSI was negative in OPCABG group (-3.4 ± 2.8%) and positive in the OMT group (5.9 ± 3.1%), indicating a better wall motion score for OPCAB patients. Surprisingly, regional WMSI improved also in non-grafted territories in the off-pump CABG group with a delta value of -3.7 ± 5.3% for left circumflex artery (LCX) area and -3.5 ± 5.4% for right coronary artery (RCA) area.ConclusionsIn patients with multivessel coronary artery disease, LIMA-to-LAD grafting is associated with an improvement in the WMSI involving also the surrounding non-LAD ungrafted segments and with the attenuation of negative global and regional ischemic ventricular remodeling.

Влияние трансмиокардиальной лазерной реваскуляризации на ангинальные симптомы и клинический эффект у пациентов с неполной хирургической реваскуляризацией.

Цель. Оценить в отдаленном периоде влияние трансмиокардиальной лазерной реваскуляризации (ТМЛР) на ангинальные симптомы и клинические результаты у пациентов, которым невозможно выполнить полную реваскуляризацию методом аортокоронарного шунтирования (АКШ).

The impact of coronary artery disease severity on late survival after combined aortic valve replacement and coronary artery bypass grafting - experience of a single cardiac surgery center.

IntroductionThe severity of coronary artery disease (CAD) may have an impact on the outcomes of patients (pts) after aortic valve replacement (AVR) and coronary artery bypass grafting (CABG).AimThe aim of the study was to analyze survival after simultaneous AVR and CABG with respect to CAD severity.Material and methodsThe study involved 143 consecutive pts (40 women and 103 men) with a mean age of 65.1 ± 7.7 years treated between 2006 and 2009. The indication for surgery was aortic stenosis accompanied by left main or three-vessel disease (group A; n = 43) and by single- or two-vessel disease (group B; n = 100). In-hospital and late mortality were analyzed. Post-discharge survival was estimated using the Kaplan-Meier method. Moreover, selected preoperative clinical and echocardiographic data as well as intraoperative variables were compared between the groups.ResultsIn-hospital mortality was 4.7% in group A and 3.0% in group B (NS). The 12-month and 48-month survival probability rates were 0.88 ± 0.05 and 0.83 ± 0.06 in group A, and 0.97 ± 0.01 and 0.92 ± 0.03 in group B, respectively (p < 0.05). Patients in group A and B differed (p < 0.05) with respect to the preoperative prevalence of arterial hypertension (65.1% vs. 42.0%) and atrial fibrillation (18.6% vs. 6.0%) as well as with regard to the rate of complete revascularization (20.9% vs. 85.0%, group A and B, respectively).ConclusionsCoronary artery disease severity impacts long-term survival after combined AVR and CABG. Patients with left main or three-vessel disease more often undergo incomplete surgical revascularization, and this fact may be one of the predictors of an unfavorable outcome.

Impact of incomplete revascularization in octagenary patients with multivessel disease

Aim: Quantify the extent of residual coronary disease after coronary bypass surgery (CABG) in very old patients (> 80) with multivessel disease and evaluate its impact on 1 year prognosis. Methods: Retrospective analysis from a single centre of 122 consecutive patients with ≥80 years of age undergoing isolated CABG between January 2005 and December 2010 (mean age 83±2; 63% men and 30% diabetics). We have identified 45 patients (37%) with complete revascularization (group A) and 77 patients (63%) with incomplete revascularization (group B). The baseline syntax score (SS), the residual syntax score after surgery (rSS) and the difference between the two syntax scores (Δ SS) were calculated. Kaplan Meier curves were used to compare the overall survival free from death and major cardiovascular events (MACCE: death, myocardial infarction, stroke and revascularization) at one year of follow-up. The area under the ROC curve (AUC) was used as a measure of discriminatory power of Syntax scores for MACCE and the test used to adjust the model was Hosmer-Lemeshow. Results: At one year follow-up (obtained in 96% of pts) freedom from primary composite end point was 79% (12,6% death, 9,0% myocardial infarction, 3,4% stroke and 0,8% revascularization). There were no differences in baseline clinical characteristics between the groups, which had similar surgical risk (median EuroSCORE II 3,91±2,8 vs 4,27±4,3; p=0,504). Group B patients showed a trend to higher rate of MACCE at 1 year (27,0 vs. 11,4; p=0,062), without differences in mortality (14,9 vs. 9,1; p=0,409). The subgroup analysis in the Kaplan-Meyer method revealed that MACCE was significantly lower in group A compared to group B (7,5% vs. 24,2% at 1 year, Log-rank p=0,033) and there was no difference in mortality between the two groups (5,0% vs. 12,1% at 1 year, Log-rank p=0,219). The SS and the ΔSS were not predictors of MACCE at 1 year (AUC: 0,51; 0,41-0,61; p=0,888; Hosmer Lemeshow: p=0,384) and (AUC: 0,56; 0,46-0,65; p0,406; Hosmer Lemeshow: p=0,904), respectively; the rSS showed a limited discriminatory power (AUC: 0,65; 0,55-0,74; p=0,049; Hosmer Lemeshow: p=0,292). Conclusions: The incomplete surgical revascularization in very old patients can be associated with more major cardiovascular events following. Further studies are needed to properly assess the impact of this strategy in this patient population.

Igg4-Related Aortitis of the Ascending Aorta in a Patient Undergoing Emergent Coronary Artery Bypass Graft: A Challenging Disease

Immunoglobulin G4 (IgG4)-related sclerosing disease in the cardiovascular system is a recently proposed disease entity, which is still unfamiliar to most clinicians. We present a case of IgG4-related periaortitis of the ascending aorta undergoing emergent surgical revascularization. During the operation we found an extremely thick and stiff aorta that led us to an incomplete surgical revascularization due to the impossibility of cross-clamp the vessel. We performed several biopsies of the aorta that confirmed the diagnosis of IgG-4 related aortitis. Before discharging the patients we perform a CT scan in order to better evaluate the real extension of the aortitis. The patient was discharged in good clinical condition and the revascularization was completed three month later performing a percutaneous transluminal angioplasty on right and circumflex coronary artery. IgG4-related periaortitis needs to be considered in the differential diagnosis in a patient with thickened aortic wall.

Giant Posterolateral Left Ventricular Aneurysm Diagnosed 6 Weeks After Incomplete Surgical Revascularization

We report the surgical repair of a true left ventricular aneurysm diagnosed 6 weeks after incomplete surgical revascularization.

Impact of incomplete surgical revascularization on survival

Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.

Reasonable Incomplete Revascularization

Incomplete coronary artery revascularization could increase the risk of death, myocardial infarction, repeat revascularization, and lifestyle-limiting angina. Data to support this hypothesis extend back to the early 1980s, when patients with incomplete surgical revascularization had an absolute 15% reduction in 5-year survival in comparison with patients with complete revascularization.1,2 This hypothesis should extend to percutaneous coronary intervention (PCI). Two New York State registry analyses demonstrated an increased risk of death associated with incomplete stent-based revascularization, and the Arterial Revascularization Therapies Study (ARTS) trial described a greater need for subsequent bypass surgery after incomplete stent revascularization.3,–,5 One study has linked incomplete stent-based revascularization with impaired improvement in left ventricular function, and thus suggests a mechanism for increased mortality risk.6 Article see p 2373 Despite the pejorative reputation of incomplete revascularization, the findings of Kim et al7 from the Asan Medical Center Multivessel Registry in the current issue of Circulation may not be entirely shocking: In this single-center registry of 1914 patients undergoing either coronary bypass surgery or drug-eluting stent implantation for multivessel coronary artery disease, no difference in absolute or adjusted rates of 5-year death or composite cardiovascular events could be discerned on the basis of the completeness of anatomic revascularization.7 The findings are not black and white; nearly 20% of the patients underwent extensive multivessel incomplete revascularization, and this group had a strong tendency toward increased adverse cardiovascular events during follow-up (30.3% versus 22.1%; adjusted hazard ratio, 1.27; 95% confidence interval, 0.97 to 1.66). Thus, the study by Kim et al is not an unqualified endorsement of leaving large territories of residual ischemic burden following PCI or coronary artery bypass grafting (CABG); instead, it provides support for a rational strategy of avoiding oculostenotic overkill and for pursuit of a …

Does Reasonable Incomplete Surgical Revascularization Affect Early or Long-Term Survival in Patients With Multivessel Coronary Artery Disease Receiving Left Internal Mammary Artery Bypass to Left Anterior Descending Artery?

Does Reasonable Incomplete Surgical Revascularization Affect Early or Long-Term Survival in Patients With Multivessel Coronary Artery Disease Receiving Left Internal Mammary Artery Bypass to Left Anterior Descending Artery?

Does Reasonable Incomplete Surgical Revascularization Affect Early or Long-Term Survival in Patients With Multivessel Coronary Artery Disease Receiving Left Internal Mammary Artery Bypass to Left Anterior Descending Artery?

The objective was to evaluate the impact of complete revascularization (CR) versus reasonable incomplete surgical revascularization (IR) in others than left anterior descending artery territory on early and late survival in patients with multivessel coronary artery disease (CAD). During a 7-year period, 8.806 consecutive patients with multivessel CAD affecting the proximal left anterior descending artery or left main stem underwent sternotomy for isolated coronary artery bypass grafting including left internal mammary artery-left anterior descending artery bypass. A total of 936 patients (10.6%) had IR of the circumflex or right coronary artery territory. IR was based on the traditional classification. Follow-up was 3.5+/-2.2 years. Patient groups were comparable regarding age (CR 67.1 versus IR 67.6 years), ejection fraction (57.2% versus 57.5%), and logEuroscore (4.5% versus 4.5%). Patients receiving IR presented with more complex CAD. Mean number of distal anastomoses was 3.0+/-0.8 CR versus 2.4+/-0.6 IR. Operation time (176 versus 187 minutes) and cross-clamp time (52 versus 56 minutes) were longer in the IR group (P<0.001). Hospital mortality was 3.3% CR versus 3.2% IR (P=0.520). Independent risk factors for hospital mortality were age, pulmonary hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and emergency indication, but not IR (P=0.922). Arterial revascularization was protective. Cumulative survival at 1-year was 93.1% CR versus 93.6% IR and at 5 years 82.2 CR versus 80.9% IR (P=0.457). In presence of left internal mammary artery-to-left anterior descending artery bypass, reasonable IR of the circumflex or right coronary artery territory did not adversely affect early or long-term survival in patients with multivessel CAD. In patients presenting with 1 poor target vessel; however, IR is a good therapeutic option and the benefit of CR should be balanced against the risks.

Does incomplete surgical revascularization affect early or long-term outcome in patients with multi-vessel coronary artery disease and LIMA to LAD grafting?

Objectives: To evaluate the impact of incomplete (IR) vs. complete revascularization (CR) in others than LAD territory in patients presenting prognostic relevant coronary artery disease (CAD).

Recurrent angina after bypass surgery: evaluation by early and late arteriography

Arteriographic correlates of recurrent angina pectoris were obtained in 98 patients undergoing both early (< 2 weeks) and late (five to 70 months, average 2.6 yrs.) postoperative angiography after coronary bypass surgery. All patients were discharged with arteriographic evidence of patency of all grafts (171 saphenous vein and six internal mammary artery) and all were asymptomatic during their early (< 3 month) postoperative follow-up. During late follow-up, recurrent angina occurred in 38 patients. The group with recurrent angina had significantly higher frequencies of progressive coronary disease (47% vs. 18%), incomplete surgical revascularization (35% vs. 15%), and graft closure (21% vs. 5%) compared to the asymptomatic group. In the total study group, 29 (30%) had progressive coronary disease with 16 (55%) having recurrent symptoms. Progressive coronary disease was present in 24% of ungrafted vessels compared to only 3% in native coronary arteries distal to graft anastomoses. The frequency of progressive coronary disease was directly related (p < 0.025) to the time interval between early and late arteriographic studies. The average annual rate of progressive disease was 10.7% of patients per year. Patients with progressive coronary disease had a higher (p < 0.05) cholesterol (264 ± 57 vs. 239 ± 37 mgm./dl.). Incomplete surgical revascularization was more common (61%) in patients operated on during the early (< 1.5 yrs.) experience with bypass surgery. Late graft closure occurred in 7.6% of all grafts and in 11% of patients. The average annual rate (attrition rate) of graft closure was 3% per year. Late graft stenosis occurred in 5% of patients but was related to angina pectoris in only one patient. The present study indicates that late recurrent symptoms may be anticipated after bypass surgery, since for the most part, they are due to progressive atherosclerotic process in the native circulation. Primary graft failure plays only a minor role in producing recurrent symptoms. Thus, continued control of risk factors, especially lipid abnormalities, is warranted after bypass surgery.