Left Anterior Descending Artery Graft Research Articles

Hemodynamic comparison between minimally invasive and conventional approaches in off-pump coronary artery bypass grafting: A randomized controlled trial

This study aimed to investigate the hypothesis that minimally invasive coronary artery bypass grafting (CABG) induces fewer hemodynamic alterations compared to conventional approaches, attributing this to reduced heart rotation during grafting. Given the critical role of hemodynamic stability in patient outcomes and the growing popularity of minimally invasive CABG, we sought to assess and compare the hemodynamic responses during left anterior descending artery grafting. This randomized controlled trial was conducted at a tertiary center, enrolling a total of 60 patients, with 30 in each group. Parameters such as heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), and perfusion index (PI) were measured at baseline, after octopus stabilization prior to grafting, at 3 minutes during grafting, and at the end of grafting. Additionally, serum lactate levels were assessed at baseline and upon completion of grafting. The baseline HR was comparable between the groups. However, the trends in HR revealed a significant increase in the conventional group after octopus stabilization (P value = 0.0038), at 3 minutes post-initiation of grafting (p < 0.001), and at the completion of grafting (P value = 0.001). MAP and CVP remained comparable at all time points. Notably, PI showed a significant increase in the conventional group during positioning (after octopus stabilization), at 3 minutes post-initiation of grafting, and at the completion of grafting. There were no significant differences in lactate levels between the groups. Despite no significant differences in MAP, CVP, and lactate levels, our findings highlight significant disparities in HR and PI between the two groups. We conclude that the observed variations in heart rate may be attributed to minimal positional changes in the minimally invasive approach compared to the conventional approach.

Analysis of a multicenter registry on evaluation of transit-time flow in coronary artery disease surgery

ObjectiveThe Evaluation of Transit-Time Flow in Coronary Artery Disease Surgery (EFCAD) registry aims to assess the influence of transit-time flow measurement (TTFM) in daily practice. MethodsEFCAD is a prospective, multicenter study involving 9 centers performing TTFM during isolated coronary artery bypass grafting. Primary end point was occurrence and risk factors of major adverse cardiac events, including perioperative myocardial infarction, urgent postoperative coronary angiogram and/or revascularization, and hospital mortality. Secondary end points were rate of graft revision during surgery and factors affecting graft flow. We respected the limit values set by the experts: mean graft flow >15 mL/minute and pulsatility index ≤5. ResultsBetween May 2017 and March 2021, 1616 patients were registered in the EFCAD database. After review, 1414 were included for analyses. Of those, 1176 were eligible for primary end point analysis. Graft revision, mainly due to inadequate TTFM values, occurred in 2% (29 patients). The primary end point occurred in 46 (3.9%) patients, and it was related with left anterior descending artery graft flow ≤15 mL/minute (odds ratio, 3.64; P < .001). Graft flow was related with number of grafts (3 vs 1-2, β = −1.6; 4-6 vs 1-2, β = −4.1; P < .001; β > 0 indicates higher flow), and graft origin (aorta vs Y, β = 9.2; in situ left internal thoracic artery vs Y, β = 3.2; in situ right internal thoracic artery vs Y, β = 2.3; P < .001). ConclusionsData from EFCAD study suggest that TTFM is reliable to evaluate graft flow, and acceptance of inadequate flow on left anterior descending artery anastomosis influence postoperative outcomes. In our opinion, TTFM assessment should be routinely used in coronary artery bypass procedures, even if interpretation depends on learning curves.

Therapeutic Strategies and Future Directions of Management for Patients with a History of Coronary Artery Bypass Grafting Who Require Secondary Coronary Revascularization

Secondary coronary revascularizations can be required due to the progression of coronary artery lesions and degeneration of bypass grafts in the long term after initial coronary artery bypass graft (CABG) surgery. It is therefore necessary to clarify the clinical characteristics of these patients and how to improve their prognosis. Optimal medical treatments, including medications, smoking cessation, and cardiac rehabilitation, are essential baseline management to prevent the progression of native coronary atherosclerosis and degradation of bypass grafts among all post-CABG patients who undergo secondary coronary revascularization as well as those who undergo initial CABG surgery in order to avoid situations requiring secondary coronary revascularization. All coronary revascularization procedures should be built upon these firm optimal medical treatments. Percutaneous coronary intervention is the current mainstay of secondary coronary revascularization approaches for patients who have symptoms of heart failure or angina pectoris because of the low invasiveness of the technique and no need for re-sternotomy. Redo-CABG is an option, especially for young patients without patency for internal thoracic artery to left anterior descending artery graft. The individualization of these approaches and improvements in medications and coronary revascularization procedures may improve the clinical outcomes and prognosis of this subgroup.

Mastering the Learning Curve for Robotic-Assisted Coronary Artery Bypass Surgery

BackgroundPrevious studies have evaluated the learning curve to achieve competency in robotic-assisted coronary artery bypass grafting (CABG) but have not identified thresholds for mastery. Robotic-assisted CABG is a minimally invasive alternative to sternotomy CABG. The purpose of this study was to evaluate the short- and long-term outcomes of this procedure and to estimate the threshold for achieving mastery. MethodsFrom 2009 to 2020, 1000 robotic-assisted CABG procedures were performed at a single institution. Robotic left internal mammary artery (LIMA) harvest followed by off-pump, LIMA–left anterior descending artery grafting using a 4-cm thoracotomy was performed. Short-term outcomes were obtained from The Society of Thoracic Surgeons database, and long-term follow-up was obtained by telephone questionnaires from dedicated research nurses for all patients more than 1 year from surgery. ResultsMean patient age was 64 ± 11 years, Society of Thoracic Surgeons predicted risk of mortality was 1.1% ± 1.5%, and 76% (758) of patients were men. Thirty-day mortality occurred in 6 patients (0.6%; observed-to-expected ratio, 0.53), 5 patients (0.5%) experienced a postoperative stroke, and postoperative LIMA patency was 97.2% (491/505). Mean procedure time decreased from 195 minutes to 176 minutes, and conversion to sternotomy decreased from 4.4% (22/500) to 1.6% (8/500) after 500 cases. Short-term outcomes suggested expertise was reached between 250 and 500 cases. Long-term follow-up was completed in 97% of patients (873/896) with a median follow-up of 3.9 years (interquartile range, 1.8-5.8), and the overall survival rate was 89% (777). ConclusionsRobotic-assisted CABG can be performed safely with excellent results even during a surgeon’s early experience. However the learning curve to achieve mastery is longer than required to achieve competency, with a threshold of approximately 250 to 500 cases.

A novel transit-time flow metric, diastolic resistance index, detects subcritical anastomotic stenosis in coronary artery bypass grafting.

Transit time flow measurement (TTFM) can detect critical anastomotic stenosis during coronary artery bypass grafting. However, the identification of subcritical stenosis remains challenging. We hypothesized that diastolic resistance index (DRI), a novel TTFM metric, is more effective in evaluating subcritical stenosis than the currently available TTFM metrics. DRI is used to measure changes in the diastolic versus systolic resistance of distal anastomosis. A total of 123 coronary bypass anastomoses in 35 patients were prospectively analyzed. During coronary artery bypass grafting, the mean graft flow (Qmean), pulsatility index, and diastolic filling were obtained. DRI was calculated using the intraoperative recordings of TTFM and arterial pressure. Postoperatively, stenosis of anastomoses was categorized into successful (<50%), subcritical (50%-74%), and critical (≥75%) via multidetector computed tomography scan. In total, 93 (76%), 13 (10%), and 17 (14%) anastomoses were graded as successful, subcritical, and critical, respectively. DRI and diastolic filling could distinguish subcritical from successful anastomoses (P<.01 and<.01, respectively), whereas Qmean and pulsatility index could not (P=.12 and .39, respectively). The receiver operating characteristic curves were established to evaluate the diagnostic ability for detecting ≥50% stenosis. In left anterior descending artery grafting (n=55), DRI had the highest area under the curve (0.91), followed by diastolic filling (0.87), Qmean (0.74), and pulsatility index (0.65). DRI and diastolic filling had a reliable diagnostic ability for detecting ≥50% stenosis during coronary artery bypass grafting. In left anterior descending artery grafting, DRI had a more satisfactory detection capability than other TTFM metrics.

Sex Differences in Coronary Artery Bypass Grafting Techniques: A Society of Thoracic Surgeons Database Analysis

BackgroundFemale patients with coronary artery disease have inferior outcomes compared with male patients, including higher mortality after coronary artery bypass graft surgery (CABG). We aimed to evaluate the association of female sex with the use of guideline-concordant CABG revascularization techniques. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for adult patients who underwent first-time isolated CABG in the United States from 2011 to 2019. The association between female sex and the odds of (1) receiving a left internal mammary artery graft for revascularization of the left anterior descending artery, (2) undergoing complete revascularization, and (3) undergoing multiarterial grafting was assessed, adjusting for procedural anatomy. ResultsAmong 1,212,487 patients meeting inclusion criteria, 75% were male (n = 911,178) and 25% were female (n = 301,309). Female sex was associated with lower unadjusted rates of revascularization with an internal mammary artery graft (93.9% vs 95.9%, P < .001), bilateral internal mammary artery graft (2.9% vs 5.6%, P < .001), or radial artery graft (3.2% vs 5.6%, P < .001). After adjustment, female patients had lower odds than males of receiving a left internal mammary artery graft to the left anterior descending artery (adjusted odds ratio 0.79; 95% confidence interval, 0.75 to 0.83; P < .001), undergoing complete revascularization (adjusted odds ratio 0.86; 95% confidence interval, 0.83 to 0.90; P < .001), and undergoing multiarterial grafting (adjusted odds ratio 0.78; 95% confidence interval, 0.75 to 0.81; P < .001). ConclusionsFemale sex was associated with 14% to 22% lower odds of undergoing guideline-concordant revascularization including left internal mammary artery to left anterior descending artery grafting, multiarterial grafting, and complete revascularization. Further investigation is necessary to determine why revascularization approaches differ by sex and to what degree sex disparities in coronary artery disease outcomes are due to surgical approach.

Hybrid Coronary Revascularization: Perspective Current State After 25 Years of Start.

Hybrid coronary revascularization (HCR) represents a minimally invasive revascularization strategy in which the durability of the internal mammary artery to the left anterior descending artery graft is combined with percutaneous coronary intervention to treat remaining lesions. It first was introduced in the mid-1990s and aspired to bring together the "best of both worlds" - the excellent patency rates and survival benefits associated with the durable left internal mammary artery graft to the left anterior descending artery alongside the good patency rates of drug-eluting stents, which outlive saphenous vein grafts to non-left anterior descending vessels. Although in theory this is a very attractive revascularization strategy, several years later, only small randomized controlled trials comparing HCR with coronary artery bypass grafting has recently emerged in the medical literature, raising concerns regarding HCR's role. In the current review, we discuss HCR's rationale, the current evidence behind it, its limitations, and procedural challenges.

Adult coronary artery bypass grafting by congenital surgeons-a propensity matched analysis.

OBJECTIVESSurgical myocardial revascularization will be increasingly needed in adult patients with congenital heart disease. We investigated the results of coronary artery bypass grafting (CABG) performed on adults by congenital cardiac surgeons at our institution.METHODSWe conducted a retrospective, single-centre study. Adults undergoing isolated or combined CABG from 2004 to 2017 were included. Early and late outcomes were analyzed for the whole cohort. Furthermore, a propensity matched analysis was conducted comparing the results of isolated CABG between congenital and adult surgeons.RESULTSA total of 514 and 113 patients had isolated and combined CABG for acquired heart disease, respectively. A total of 33 patients had myocardial revascularization at the time of surgery for congenital heart disease. Overall early mortality was 1.2%, the rate of re-exploration for bleeding was 4.5%, and an internal mammary artery to left anterior descending artery graft was used in 85.6% patients. One-year survival was 97.5% (96.2–98.8%), and 5-year survival was 88.0% (84.8–91.3%). After propensity matching (468 pairs), early mortality (0.6% vs 1.2%, P = 0.51), re-exploration for bleeding (3.6% vs 3.0%, P = 0.72), use of internal mammary artery to left anterior descending artery graft (92.7% vs 91.9%, P = 0.70) and late survival did not differ between congenital surgeons and adult surgeons, respectively.CONCLUSIONSSurgical myocardial revascularization can be required for adult congenital patients in a broad spectrum of clinical situations. Despite lower volumes, congenital cardiac surgeons perform CABG safely and with results that are comparable to those of the adult surgeons at our centre.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period. Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%. In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

Recovery of hibernating myocardium using stem cell patch with coronary bypass surgery

ObjectiveThis study aims to investigate the utility of mesenchymal stem cells (MSCs) applied as an epicardial patch during coronary artery bypass graft (CABG) to target hibernating myocardium; that is, tissue with persistently decreased myocardial function, in a large animal model. MethodsHibernating myocardium was induced in juvenile swine (n = 12) using a surgically placed constrictor on the left anterior descending artery, causing stenosis without infarction. After 12 weeks, single-vessel CABG was performed using left internal thoracic artery to left anterior descending artery graft. During CABG, an epicardial patch was applied to the hibernating myocardium region consisting either of MSCs grown onto a polyglactin mesh (n = 6), or sham polyglactin mesh without MSCs (n = 6). Four weeks after CABG and patch placement, cardiac magnetic resonance imaging was performed and cardiac tissue was examined by gross inspection, including coronary dilators for vessel stenosis and patency, electron microscopy, protein assays, and proteomic analysis. ResultsCABG + MSC myocardium showed improvement in contractile function (78.24% ± 19.6%) compared with sham patch (39.17% ± 5.57%) during inotropic stimulation (P < .05). Compared with sham patch control, electron microscopy of CABG + MSC myocardium showed improvement in mitochondrial size, number, and morphology; protein analysis similarly showed increases in expression of the mitochondrial biogenesis marker peroxisome proliferator-activated receptor gamma coactivator 1-alpha (0.0022 ± 0.0009 vs 0.023 ± 0.009) (P < .01) along with key components of the electron transport chain, including succinate dehydrogenase (complex II) (0.06 ± 0.02 vs 0.14 ± 0.03) (P < .05) and adenosine triphosphate synthase (complex V) (2.7 ± 0.4 vs 4.2 ± 0.26) (P < .05). ConclusionsIn hibernating myocardium, placement of a stem cell patch during CABG shows promise in improving myocardial function by improving mitochondrial morphology and function.

Quality of life in patients after coronary artery bypass grafting with bilateral internal thoracic artery versus single internal thoracic artery.

IntroductionThe left internal thoracic artery to the left anterior descending artery graft is recognized as the gold standard for coronary revascularization. We compared quality of life (QoL) in patients who received bilateral internal thoracic arteries (BITA) and those with a single internal thoracic artery (SITA) graft.AimTo assess QoL during a 10-year follow-up in patients who underwent coronary artery bypass grafting (CABG) with BITA vs. SITA.Material and methodsWe recruited 300 patients with multivessel coronary artery disease who underwent CABG from January 2005 to October 2010. Mean duration (standard deviation – SD) of follow-up was 3568 ±409 days. QoL was measured subjectively using a Likert scale and objectively by the WHOQOL-BREF questionnaire. Patients were interviewed by telephone.ResultsBITA patients reported marked improvement and improvement more often than SITA patients (58% vs. 43.3%, p = 0.02). Marked deterioration was noted by 2% of BITA patients and 3.3% of SITA patients (p = 0.03). Summarized results of the WHOQOL-BREF questionnaire showed significantly better QoL in the BITA group (median: 15.0) vs. SITA group (median: 14.75) (p = 0.02). There were more angina-free patients in the BITA group (84%) compared to SITA patients (72.7%) (p = 0.006). QoL did not correlate with patients’ body mass index (p = 0.10) or residence status (p = 0.51), but there was a weak negative correlation between QoL and patients’ age (r = –0.14, p = 0.01).ConclusionsSurgical coronary revascularization using BITA improves QoL, particularly when measured by a Likert scale.

Dynamic Kinking of Left Internal Mammary Artery Graft

A 61-year-old man with history of coronary artery disease and coronary artery bypass graft presented with chest pain. A left heart catheterization showed a new kink in the body of his left internal mammary artery to left anterior descending artery graft. The kink improved with inspiration, which suggests re-assessment of similar cases should be done during deep inspiration. (Level of Difficulty: Intermediate.)

AN UNUSUAL CASE OF NON SMALL CELL LUNG CANCER PRESENTING AS NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Non-ST-elevation myocardial infarction (NSTEMI) is a mismatch in the myocardial oxygen demand and consumption. Common causes include poor coronary flow, unmet increased oxygen demand, and cardiac inflammation. We present a case of NSTEMI as a result of a cause not yet reported in the literature. CASE PRESENTATION: An 84-year-old man with a history of coronary artery disease (CAD), coronary artery bypass grafting, hypertension, 10 pack-year smoking history presented with a 1-week history of typical chest pain. Review of systems was otherwise non-contributory. He reported medication adherence and denied illicit drug use. Initial vitals were stable. Electrocardiogram (EKG) was unchanged from prior with no dynamic ST changes. Cardiac enzymes showed a troponin of 0.720 ng/ml, CKMB of 72.50 ng/ml and CK of 585 IU/L. Heparin drip was started for presumed NSTEMI. Troponins subsequently rose to 22.530 ng/ml and peaked at 49.160 ng/ml after which they trended downwards. Serial EKGs were unchanged. His chest pain resolved with the initiation of heparin drip. Given the downtrend in troponins and lack of EKG changes, cardiac catheterization was not performed. The echocardiogram revealed a right ventricular mass obstructing the right ventricular outflow tract (RVOT) without evidence of right ventricular strain. As the position of the mass was unclear a CT chest and cardiac MRI were done which showed an anterior mediastinal mass 5.0 cm x 5.5 cm x 6.5 cm effacing the right ventricle and pulmonary artery and also encasing the left main coronary artery, the left internal mammary artery and left anterior descending artery graft with invasion of the superficial epicardial margin of the left ventricle basal anterior segment. The heparin drip was discontinued at this point given the risk of hemorrhagic conversion of the mass. Biopsy of the mass revealed a non-small cell lung cancer (NSCLC). Further imaging revealed no metastatic lesions. Due to the size of the mass and cardiac invasion, he was not a candidate for cardiothoracic surgery. Given that he was stable from a cardiac standpoint, he was discharged with followup with hematology-oncology. DISCUSSION: Cardiac metastasis has been reported in 9% of NSCLC cases. It typically presents as dyspnea and pleuritic chest pain. While myocardial metastasis has been reported to be associated with acute STEMI [2], its presentation as NSTEMI has not been previously reported [1]. We hypothesize that this unusual presentation may have resulted from the encasement of the coronary vessels by the tumor, which led to disruption and stasis of blood flow promoting a prothrombotic state. This may have resulted in a thrombus causing ischemia which responded to heparin as treatment. CONCLUSIONS: Cardiac metastasis should be considered as a differential diagnosis for NSTEMI in patients with CAD presenting with typical chest pain given the potential to alter treatment Reference #1: Chiles, C., Woodard, P., Gutierrez, F., Link, K. (2001). Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics, 21(2), 439-449. Reference #2: Suga, T., Akuzawa, N., Hatori, T., Imai, K., Kitahara, Y., & Kurabayashi, M. (2015). ST segment elevation in secondary cardiac cancer: a case report and review of the literature. International journal of clinical and experimental medicine, 8(5), 7719-27. DISCLOSURES: No relevant relationships by Hassaan Arshad, source=Web Response No relevant relationships by Aishwarya Bhardwaj, source=Web Response No relevant relationships by Dayna Panchal, source=Web Response no disclosure on file for Kumar Satya; No relevant relationships by Umar Jamshed Sharif Khawaja, source=Web Response No relevant relationships by Rehan Umar, source=Web Response No relevant relationships by Jun Chih Wang, source=Web Response

Hybrid Myocardial Revascularization or Multivessel Minimally Invasive Direct Coronary Artery Bypass: Two Case Reports

Since the first introduction of direct grafting of the Left Anterior Descending artery (LAD) by Kolessov in 1967, the tendency in myocardial revascularization has been towards less invasive techniques. New developments are increasingly making it possible to extend the indication for Robotically Assisted Minimally Invasive Direct Coronary Artery Bypass (RAMIDCAB) surgery to patients with triple vessel disease. Here, we present two cases in which complete revascularization was successfully achieved. The first patient underwent a hybrid procedure involving RA-MIDCAB followed by Percutaneous Coronary Intervention (PCI); the other patient received RA-MIDCAB in which bilateral internal mammary arteries were used as a conduit for grafting. The implications, limitations and challenges of these interventional strategies are discussed. Furthermore, it is suggested that minimally invasive strategies might have important benefits especially for high-risk patients, and that these strategies should be included in decisionmaking by the Heart Team if available.

Minimally invasive coronary artery bypass: Twenty-year experience

ObjectiveMinimally invasive direct coronary artery bypass for the left thoracic artery on the left anterior descending artery is a safe and less traumatic surgical technique. We retrospectively evaluated long-term outcomes in a large series of patients undergoing minimally invasive direct coronary artery bypass. MethodsFrom 1997 to 2016, 1060 patients underwent minimally invasive direct coronary artery bypass: 646 patients (61%) with isolated proximal left anterior descending disease and 414 patients (39%) with multivessel disease as a part of hybrid coronary revascularization or in association with medical therapy. Long-term follow-up, major cardiac and cerebral adverse events, and freedom from angina were analyzed. ResultsMean age of patients was 71 ± 12.5 years, and median European System for Cardiac Operative Risk Evaluation II was 3.2% (interquartile range, 0.6%-7.8%). Postoperative death occurred in 9 patients (0.8%), and perioperative stroke occurred in 3 patients (0.3%). An angiogram or computed tomography scan was performed and was available in patients within 10 years of follow-up (n = 696), demonstrating a 96.8% graft patency rate. At 13.9 ± 5.6 years of follow-up, no surgical reintervention was performed for left thoracic artery on left anterior descending artery graft failure, but 14 patients underwent left anterior descending or left thoracic artery on left anterior descending artery percutaneous coronary intervention. Kaplan–Meier survival curve shows 87.1% at 5 years (95% confidence interval, 81-92.5), 84.3% at 10 years (95% confidence interval, 77.1-91.4), and 79.8% at 15 years (95% confidence interval, 72.2-87.3). Survival freedom from major adverse events was 87.0% (95% confidence interval, 85.9-88.1) at 5 years and 70.5% (95% confidence interval, 66.4-74.6) at 15 years. ConclusionsMinimally invasive direct coronary artery bypass can be safely performed with low postoperative mortality and morbidity with excellent short- and long-term survival and freedom from major adverse events and angina with a reduced surgical invasiveness.

Total Arterial Off-Pump Coronary Artery Bypass Grafting

Background:Arterial grafts had better mid-term and long-term patency than saphenous vein grafts in coronary artery bypass grafting (CABG). We summarized our experience with total arterial off-pump coronary artery bypass grafting (OPCAB) and assessed the early clinical results, surgical complications, and follow-up.Methods:From January 2007 to May 2017, 508 coronary artery disease patients undergoing total arterial OPCAB were enrolled. Clinical features, approaches, outcomes of surgical treatments, and follow-up data of these patients were studied retrospectively. A total of 122 patients underwent single left internal mammary artery (IMA)-left anterior descending artery grafts, whereas the other 386 patients underwent multiple vessel grafts.Results:The average distal anastomosis was 2.34 ± 0.97 (range: 1–4). All the patients were discharged from hospital except one died. A total of 457 (90.32%) patients were followed up. In the 4-, 7-, and 10-year follow-up groups, the rate of death from any cause was 1.19%, 6.47%, and 10.67%; rate of cardiac death was 0.60%, 2.88%, and 3.33%; rate of repeat revascularization was 0.00%, 3.60%, and 8.67%; rate of ischemic symptoms was 1.79%, 7.91%, and 11.33%; and incidence of stroke was 2.38%, 4.32%, and 6.67%, respectively. Poor medication adherence was observed in 9.38% of the follow-up population.Conclusions:Total arterial OPCAB with bilateral IMA, radial artery, and right gastroepiploic artery grafting yielded satisfactory early and midterm outcomes in this patient group, without a significant increase in early mortality or morbidity. Moreover, the long-term outcomes are also positive.

21-Year Survival of Left Internal Mammary Artery–Radial Artery–Y Graft

BackgroundIn 1999, Royse et al. reported on the left internal mammary artery, radial artery, Y-graft technique (LIMA-RA-Y), which achieves total arterial revascularization (TAR). However, the most common coronary reconstruction remains LIMA and supplementary saphenous vein grafts (LIMA + SVG). ObjectivesThe goal of this study was to conduct a survival comparison of LIMA-RA-Y versus the conventional LIMA + SVG. MethodsOf the original 464 LIMA-RA-Y patients reported (1996 to 1998), 346 were from the Royal Melbourne Hospital. Survival at June 2017 was compared with a group of 534 patients from 1996 to 2003 from the same institution who received LIMA + SVG, or 5,800 patients who received TAR with different grafting configurations. Propensity score matching (PSM) was performed with 1:1 matching using 26 variables. Comparisons used Kaplan-Meier (KM) and Cox proportional hazards methods. LIMA-RA-Y was compared with LIMA + SVG in which all non–left anterior descending artery grafts were performed with either composite RA or aorta-coronary SVG with no use of right internal mammary artery. We also conducted a comparison of LIMA-RA-Y versus TAR. ResultsBaseline characteristics of the LIMA-RA-Y group (n = 346) compared with LIMA + SVG (n = 534) after PSM (n = 232 pairs) did not differ (3.3 ± 0.8 grafts per patient). Survival was worse for LIMA + SVG in the unmatched groups (KM, p < 0.001) and for PSM groups (KM, p = 0.043; Cox proportional hazards ratio: 1.3; 95% confidence interval: 1.0 to 1.6; p = 0.038). Survival did not differ between LIMA-RA-Y and other TAR (n = 5,800) patients before, or after, PSM (n = 332 pairs). ConclusionsUse of LIMA + SVG has worse survival than LIMA-RA-Y in achieving total arterial revascularization.

The Incremental Value of Three or More Arterial Grafts in CABG: The Effect of Native Vessel Disease

We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD). Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n= 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n= 3,678, 30.8%) and three arteries (n= 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD. Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD. Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients.

Incremental Value of Increasing Number of Arterial Grafts: The Effect of Diabetes Mellitus

Multiarterial coronary grafting with two arterial grafts leads to improved survival compared with conventional single artery based on left internal thoracic artery to left anterior descending artery and saphenous vein grafts. We investigated whether extending arterial grafting to three or more arterial grafts further improves survival, and whether such a benefit is modified by diabetes mellitus. We analyzed 15-year coronary artery bypass graft surgery mortality data in 11,931 patients (age 64.3 ± 10.5 years; 3,484 women [29.2%]; 4,377 [36.7%] with diabetes mellitus) derived from three US institutions (1994 to 2011). All underwent primary isolated left internal thoracic artery to left anterior descending artery grafting with at least two grafts: one artery (n= 6,782; 56.9%); two arteries (n= 3,678; 30.8%); or three or more arteries (n= 1,471; 12.3%). Long-term survival was estimated by Kaplan-Meier methods. Propensity score matching and comprehensive covariate adjustment (Cox regression) were used to derive long-term risk-adjusted hazard ratio (HR) with 95% confidence interval (CI) for increasing number of arterial grafts in the overall cohort and for diabetes and no-diabetes cohorts. Radial artery (94%) and right internal thoracic artery (6%) were used as additional arterial grafts. Multivariate analysis in all patients showed that diabetes was associated with decreased survival (HR 1.43, 95% CI: 1.34 to 53), whereas increasing number of arterial grafts was associated with decreased mortality (one artery HR 1.0 [reference]; two arteries HR 0.87, 95% CI: 0.80 to 0.95; and three arteries HR 0.83, 95% CI: 0.72 to 0.95). Pairwise comparisons also showed an incremental benefit of additional arterial grafts: two arteries versus one artery, HR 0.89 (95% CI: 0.80 to 0.98); and three arteries versus one artery, HR 0.80 (95% CI: 0.68 to 0.94). A three-artery versus two-artery survival advantage trend was also noted, but was not significant in either the overall study cohort (HR 0.90, 95% CI: 0.75 to 1.07), the diabetes cohort (HR 0.79, 95% CI: 0.60 to 1.03), or the no-diabetes cohort (HR 01.00, 95% CI: 0.79 to 1.26). Among diabetes patients, the survival advantage of two arteries versus one artery was modest (HR 0.96, 95% CI: 0.72 to 1.11), whereas it was significant for three arteries versus one artery (HR 0.74, 95% CI: 0.58 to 0.96). Analyses of propensity matched subcohorts were also consistent. Increasing number of arterial grafts improves long-term survival and supports extended use of arterial grafts in coronary artery bypass graft surgery, irrespective of diabetes status.

Competitive Coronary Flow between the Native Left Anterior Descending Artery and Left Internal Mammary Artery Graft: Is It a Surrogate Angiographic Marker of Over-or-Unnecessary Revascularization Decision in Daily Practice?

Overdiagnosis and overtreatment are often thought of as relatively recent phenomena in modern medicine, influenced by a contemporary combination of technology, specialization, payment models, marketing, and supply-related demand. Several investigators have reported discrepancies between the angiographic and functional severity of coronary angiographic stenosis. However, the visual anatomic assessment of the coronary lesion severity continues in daily practice. We evaluated the consecutive all coronary angiograms performed between January 2015 and December 2015 and examined only patients who had previous coronary artery bypass grafting (CABG) to analyze the cases with regard to presence of the competitive flow (CF) between the native left anterior descending coronary artery (LAD) and left internal mammary artery (LIMA) graft. A total of 8,248 diagnostic coronary angiographies were performed between January 2015 and December 2015 at our facility. Of these, 886 coronary angiographies of CABG patients were detected. Whereas LIMA graft occlusion detected in 19 patient (2.1%), the LIMA-LAD CF rate was found in 86 (9.7%) CABG patients. The angiographic severity of the LAD stenosis in CF group evaluated as mild in 20 (25%), moderate in 61 (70%), and severe coronary artery disease in 4 (5%) patients. Our results showed that there is 9.7% rate of LIMA-LAD CF. Therefore, some unnecessary coronary stenting or CABG procedures might have been performed due to limited use of functional testing for clinical decision making. The functional angiography should play a more prominent role in catheterization laboratories as recommended by current revascularization guidelines to prevent overdiagnosis, misdiagnosis, or incorrect treatment decisions.