Myocardial Revascularization In Patients Research Articles

The Role of Coronary Physiology in Contemporary Percutaneous Coronary Interventions.

Invasive assessment of coronary physiology has radically changed the paradigm of myocardial revascularization in patients with coronary artery disease. Despite the prognostic improvement associated with ischemia-driven revascularization strategy, functional assessment of angiographic intermediate epicardial stenosis remains largely underused in clinical practice. Multiple tools have been developed or are under development in order to reduce the invasiveness, cost, and extra procedural time associated with the invasive assessment of coronary physiology. Besides epicardial stenosis, a growing body of evidence highlights the role of coronary microcirculation in regulating coronary flow with consequent pathophysiological and clinical and prognostic implications. Adequate assessment of coronary microcirculation function and integrity has then become another component of the decision-making algorithm for optimal diagnosis and treatment of coronary syndromes. This review aims at providing a comprehensive description of tools and techniques currently available in the catheterization laboratory to obtain a thorough and complete functional assessment of the entire coronary tree (both for the epicardial and microvascular compartments).

Quality of life after myocardial re-vascularisation in patients with acute coronary syndrome during the coronavirus disease 2019 pandemic: a prospective observational study

Aim. To study the quality of life and how it is influenced by different factors in the long term after myocardial re-vascularisation in patients with coronary artery disease who had acute coronary syndrome during the coronavirus disease 2019 (COVID-19) pandemic.Methods. We examined 658 patients with coronary artery disease and acute coronary syndrome (mean age 66.4 ± 4.3 years). Percutaneous coronary intervention (600 patients) and coronary artery bypass grafting with cardio-pulmonary bypass (58 patients) were performed. Six months after myocardial re-vascularisation, we assessed patients' quality of life using the SF-36 questionnaire. We identified factors that affect the quality of life using multivariate regression analysis.Results. After myocardial revascularisation, the patients had a reduced overall indicator of physical health (< 40 points). The overall indicator of psycho-emotional health was higher than physical (p < 0.002) but did not exceed 50 points. We noted the adverse effect of COVID-19 (regardless of disease severity) on the assessment. Also, COVID-19 was associated with increased anxiety. A history of concomitant diabetes mellitus, obesity, stroke and percutaneous coronary intervention had a negative effect on the overall indicators of physical and mental health.Conclusion. Patients with coronary artery disease who had acute coronary syndrome after myocardial re-vascularisation are characterised by reduced indicators of physical and average indicators of mental health in the long term. COVID-19, regardless of disease severity, has a negative impact on patients' general state of health, social activity and emotional background. A history of diabetes mellitus, obesity, stroke and percutaneous coronary intervention adversely affects the physical and mental health indicators. Received 4 August 2021. Revised 31 August 2021. Accepted 1 September 2021. Funding: This work was carried out within the framework of the state task of the Ministry of Health of the Russian Federation (No. 121031300225-8). Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: O.V. Kamenskaya, V.V. LomivorotovData collection and analysis: A.S. KlinkovaStatistical analysis: A.S. KlinkovaDrafting the article: A.S. Klinkova, I.Yu. LoginovaCritical revision of the article: O.V. Kamenskaya, A.M. ChernyavskiyFinal approval of the version to be published: A.S. Klinkova, O.V. Kamenskaya, I.Yu. Loginova, A.M. Chernyavskiy, V.V. Lomivorotov

Single-center register of myocardial revascularization in patients with coronary artery disease and acute coronary syndrome in the context of COVID-19 pandemic

Aim. To assess the short- and long-term outcomes of myocardial re- vascularization (MR) in patients with coronary artery disease (CAD) and acute coronary syndrome (ACS) in the context of coronavirus disease 2019 (COVID-19) pandemic.Material and methods. In the period from April to August 2020, 550 patients with CAD and ACS were included in the register. Emergency percutaneous transluminal coronary angioplasty (n=499) and on-pump coronary artery bypass grafting (CABG) (n=51) were performed. The follow-up period lasted 6 months. The pattern of complications after MR and effects of COVID-19 were analyzed.Results. The studied cohort is represented by patients with CAD >65 years old. ST segment elevation ACS was detected in 23%, acute myocardial infarction — in 59,1%, in other cases — unstable angina. During hospitalization after MR, atrial fibrillation prevailed among cardiovascular complications (4,7%). During this period, 29 (5,3%) patients was diagnosed with COVID-19. In the short-term period after MR, 3 (0,5%) people died due to COVID-19 complications-. In the long-term period after MR, 4 (0,7%) cases of non-fatal stroke were registered, while repeated MR — in 7,1%. The all-cause mortality rate was 1,3% (n=7), of which 57,1% of patients died due to COVID-19 complications. In the subgroup of patients who underwent CABG, the greatest number of in-hospital complications was noted, where exudative pleurisy, atrial fibrillation and anemia prevailed. Of the patients with COVID-19, pneumonia in the short-and long-term posto perative periods was recorded in 48,3 and 61,3%, respectively. Pneumonia is associated with respiratory failure, cardiac dysfunction, and anemia. The risk of COVID-19 pneumonia during the entire follow-up period was higher in patients with ACS who underwent CABG (odds ratio, 19,4; confidence interval: 13,3-26,1; p<0,001). The overall survival rate was 98,7%.Conclusion. COVID-19 infection in patients with ACS after MR effects pattern of postoperative complications. The proportion of COVID-19 pneumonia in patients with ACS in hospital, short- and long-term postoperative periods after MR significantly exceeds that in the general population. The leading factor associated with COVID-19 pneumonia in patients with ACS is on-pump CABG.

Haemodynamics Support during Surgical Myocardial Revascularisation in Patients with Systolic Left Ventricular Dysfunction

Coronary heart disease remains a leading cause of death worldwide, and coronary bypass surgery -- the treatment standard in haemodynamically significant multivessel and/or trunk coronary stenosis. Intraoperative haemodynamics support during coronary artery bypass grafting (CABG) in patients with reduced ejection fraction currently remains controversial. Manifold evidence favours CABG with no extracorporeal circulation in higher risk patients to avoid the system’s frequent complications of blood transfusion, renal failure, bleeding, wound infection, cerebrovascular events and humoral disturbances. On the other hand, CABG with extracorporeal circulation and heart arrest allows a bloodless operating field and complete revascularisation in most, often very complex, cases. The complication rate and outcome in beating-heart surgery are reckoned to depend directly on the relevant surgeon’s and clinic experience, which makes many relinquish the technique due to a limited history of skill. This essay overviews the current state of the art, discussions of recent systematic studies on intraoperative haemodynamics support in patients with reduced left ventricular ejection fraction and touches upon the importance of surgeon’s experience for the operation outcome.

Selection of optimal endarterectomy technique in the left anterior descending artery for diffuse coronary atherosclerosis

Aim. To determine the optimal method for performing coronary artery endarterectomy (СE) based on immediate and long-term outcomes of coronary artery bypass grafting (CABG) in combination with open or closed CE in the left anterior descending artery (LAD).Material and methods. This retrospective study included 103 patients who underwent CABG in combination with closed CE and 204 after open CE in the LAD during the period from 2003 to 2016. In both groups, the patient age was comparable (65 years [56; 69] vs 67 years [58; 72] (p=0,263)). There were more men (88,3% vs 81,4% (p=0,421). The mean follow-up period was 94 months [38; 180]. Long-term outcomes were assessed in 86,4% (n=89) and 83,8% (n=171) of patients from the closed and open CE groups, respectively (p=0,141). Angiographic data were studied in 75,3% and 67,3% of patients, respectively (p=0,441).Results. In the closed and open CE groups, in-hospital mortality was 4,8% and 1,5% (p=0,0012), incidence of perioperative myocardial infarction — 11,6% vs 2,5%, (p<0,001), survival rate after 7,8 years — 81,3±5,1% and 84,4±3,2% (p=0,342), respectively. The patency of arterial shunts was significantly higher in the open CE group — 93,1% vs 80,6% (p=0,004). At the same time, the patency of venous shunts in the long-term period between the groups was comparable — 70,1% vs 73,7% (p=0,314).Conclusion. Open CE in combination with CABG provides better immediate outcomes compared to closed CE. Long-term survival and freedom from angina between the groups were comparable. In the long-term period, the patency of internal thoracic artery after open CE is better than after the closed technique. Open CE is a safe and effective method to achieve complete myocardial revascularization in patients with severe diffuse LAD atherosclerosis.

Myocardial revascularization in patients with acute coronary syndrome in the context of COVID-19 pandemic: a single-center prospective cohort study

Aim. To assess the outcomes of myocardial revascularization (MR) and identify risk factors for early postoperative complications in patients with coronary artery disease (CAD) with acute coronary syndrome (ACS) in the context of coronavirus disease 2019 (COVID-19) pandemic.Material and methods. The study included 769 patients aged 67,0±4,4 years with CAD with ACS in the period from April to October 2020. In an expedited manner, percutaneous transluminal coronary angioplasty (n=699) and on pump coronary artery bypass grafting (CABG) (n=70) were performed. All patients underwent a COVID-19 rapid tests. After MR, the following outcomes were recorded: adverse cardiovascular events and other complications; various surgical interventions; bilateral COVID-19 pneumonia; death. The follow-up period lasted 30 days.Results. During the hospitalization, COVID-19 was detected in 5,3% of patients (n=41). Among them, bilateral multisegmental pneumonia developed in 48,8%. Among infected patients, COVID-19-related mortality in the early postoperative period was 9,8%. The all-cause mortality rate was 0,7%. On pump CABG significantly increases the risk of developing COVID-19 pneumonia (odds ratio (OR), 23,2; 95% confidence interval (CI) 14,2-35,4; p<0,001). After MR, COVID-19 pneumonia was associated with respiratory (OR, 7,6; 95% CI, 4,3-11,5; p=0,001) and heart failure (OR, 4,2; 95% CI, 2,9-8,6; p=0,001), atrial fibrillation (OR, 8,3; 95% CI, 4,1-13,9; p=0,001), as well as with all-cause mortality (OR, 10,3; 95% CI, 5,2-16,7; p=0,005). Recurrent transmural myocardial infarction in patients with CAD was associated with heart failure after MR (OR, 7,1; 95% CI, 2,4-12,6; p=0,012).Conclusion. Conducting on pump CABG in patients with CAD with ACS is the leading trigger for developing COVID-19 pneumonia, which, during hospitalization after MR, was associated not only with respiratory complications, but also with impaired heart function, which significantly increases the death risk in this category of patients.

Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.

The Relationship Between Serum Uric Acid at Different Concentrations of Lipid Indices and the Risk of Myocardial Revascularization in Patients With Acute Coronary Syndrome: A Retrospective Analysis.

Objective: Both serum uric acid (SUA) levels and lipid components, such as LDL, HDL, and Lp(a), have been reported to associate with CAD. However, the influence of SUA status at different concentrations of lipid indices for the risk of myocardial revascularization (MRT) in ACS patients is currently unknown.Methods: We retrospectively analyzed a hospital-based sample of 14,234 ACS patients with no previous history of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. All patients went for coronary angiography. Binary logistic regression models were performed, and the odds ratios (OR) at 95% confidence interval (CIs) were used to approximate the associated risk of UA and lipid profile for myocardial revascularization, with the lowest quartile/tertile serving as the reference category.Results: Overall, 8,818 (61.9%) patients undergone MRT out of 14,234 patients. Elevated SUA and HDL were negatively associated with an increased likelihood of MRT during admission (P < 0.001). However, LDL and Lp(a) levels were positively associated with MRT among ACS patients. Furthermore, interaction analyses between SUA and lipid profiles, particularly LDL and Lp(a), compared with those in the lowest quartile of SUA levels, show that patients in higher SUA quartiles grouped by lipid components had a significantly lower chance of undergoing MRT, with the lowest OR (95%CI) for subjects being 0.222 (0.170-0.290), 0.478 (0.374-0.612), and 0.604 (0.468-0.780) in LDL tertiles, being 0.671(0.523-0.862), 0.316(0.242-0.413), and 0.410 (0.310-0.542) in Lp(a) tertiles, respectively. In the three tertiles of HDL levels, the incidence of MRT dropped steadily as SUA levels increased. Also, we further analyzed ACS patients without diabetes. Compared with the first quartile of SUA levels, the risks of MRT were significantly lower in different tertiles of lipids components [LDL, Lp(a), HDL].Conclusion: An increase in SUA levels may decrease the chance of undergoing MRT in ACS patients, even in those with increased Lp(a) and LDL-c. Elevated serum uric acid may play a protective role during an acute stage of ACS.

СЛУЧАЙ АОРТОКОРОНОРНОГО ШУНТИРОВАНИЯ У БОЛЬНОГО С ИНФАРКТОМ МИОКАРДА С ПОДЪЕМОМ СЕГМЕНТА ST, МНОГОСОСУДИСТЫМ ПОРАЖЕНИЕМ КОРОНАРНОГО РУСЛА И НИЗКОЙ ФРАКЦИЕЙ ВЫБРОСА

For decades, coronary artery bypass grafting (CABG) has been the main method of myocardial revascularization in patients with coronary artery disease, including those with acute coronary syndrome (ACS). Over the past decades, with the development of endovascular interventions and the development of drug-eluting stents, percutaneous coronary intervention (PCI) has become the main method of revascularization after ACS. [1,6]. Acute coronary syndrome (ACS) includes clinical manifestations such as unstable angina pectoris (NS), acute non-ST-segment elevation myocardial infarction (STEMI), and ST-segment elevation myocardial infarction (STEMI). Approximately 40% of all patients diagnosed with ACS have multivessel coronary artery disease, for which coronary artery bypass grafting (CABG) is better than PCI. [2]. The majority of studies comparing PCI and CABG have mainly included patients with stable coronary artery disease who underwent planned myocardial revascularization, rather than those requiring emergency or urgent myocardial revascularization. Thus, the results of these studies have limited applicability to patients with ACS. However, the long-term results of these studies, in particular the low need for re-revascularization, a lower rate of re-myocardial infarction, and the survival benefits of CABG, still need to be considered when determining the best course of treatment for ACS. The current recommendations for treatment in most patients with ACS give preference to early revascularization using PCI or CABG [3, 4]. Thus, our main goal here is to provide the current indications and options for surgical revascularization of the coronary arteries, including current guidelines and the latest published literature. In STEMI patients, early PCI of the main lesion remains the gold standard because it provides the fastest revascularization of the ischemic myocardium and is generally better tolerated than emergency CABG [5]. Since up to 50% of STEMI patients have multivessel coronary artery disease, early arterial revascularization without myocardial infarction has been recommended to provide optimal opportunities for myocardial rescue, reduction of ischemic watershed and improvement of left ventricular function [6,7]. A clinical case of successful beating coronary artery bypass grafting in a patient with ST-segment elevation myocardial infarction, multivessel coronary artery disease and low ejection fraction. The patient was discharged on the 11th day after surgery without complications.

Аналіз віддалених результатів комплексного лікування ішемічної хвороби серця упацієнтів із предіабетом та явним цукровим діабетом

Актуальність. Попри сучасні методи діагностики та лікування порушень обміну глюкози, цукровий діабет (ЦД) залишається незалежним фактором ризику та удвічі збільшує кількість серцево-судинних подій (ішемічна хвороба серця (ІХС), ішемічний інсульт, смерть). Ефективність сучасних методів реваскуляризації міокарда у хворих з цукровим діабетом потребує подальшого вивчення. Мета: оцінка факторів ризику та віддалених результатів реваскуляризації коронарних артерій у пацієнтів із ішемічною хворобою серця та супутнім предіабетом або явним ЦД. Матеріали та методи. У ретроспективному дослідженні брали участь 120 пацієнтів із ІХС, яким було проведено реваскуляризацію коронарних артерій. Залежно від глікемічного статусу пацієнти були розподілені на дві групи: І група (основна група)— хворіли на предіабет або ЦД (n=58); ІІ група (контрольна група)— пацієнти без порушення глікемії (n=62). Ступінь ураження коронарних артерій визначали за результатами коронарографії. Результати лікування у пацієнтів обох груп оцінювали за наявністю прогресування атеросклерозу коронарних артерій (повторні втручання з приводу появи нових атеросклеротичних уражень або рестенозу попередньо імплантованого стента) та показниками летальності. Середній термін спостереження хворих у двох групах становить 3роки (мінімальний— 24місяці). Результати. У пацієнтів І групи, із предіабетом та явним ЦД, переважає трисудинне ураження коронарних артерій (43,1 vs 16,1%, p&lt;0,05); хронічна оклюзія судин серця діагностується частіше, ніж у пацієнтів ІІ групи (43,1 vs 25,8%, p&lt;0,05), що характеризує більш тяжчий перебіг захворювання. Ухворих основної групи порівняно із групою контролю захворюваність на інфаркт міокарда (45,9 vs 33,9%, відношення шансів (OR) 6,1 (95% довірчий інтервал (ДІ) 2,76–13,6) p&lt;0,05), інсульт (13,8 vs 3,2%, OR 4,8 (95% ДІ 0,97–23,6) p&lt;0,05) та хронічну ниркову недостатність (10,3 vs 1,6%, OR 7,0 (95% ДІ 0,82–60,4) p&lt;0,05) є вірогідно більшою. На відміну від пацієнтів без ЦД, у хворих першої групи показники систолічної функції серця вірогідно нижчі (48,9±11,9% vs 54,61±7,56%, p&lt;0,05). Черезшкірне коронарне втручання є методом вибору реваскуляризації коронарних артерій у пацієнтів із ІХС, проте аортокоронарне шунтування частіше застосовується за наявності ЦД (24,1 vs 6,5%, p&lt;0,05). Прогресування атеросклерозу коронарних артерій переважає у пацієнтів із порушеним обміном глюкози (19,0 vs 6,5%, OR 3,4 (95% ДІ 1,01–11,3) p&lt;0,05). Летальність у пацієнтів І групи є вищою (12,1 vs 1,6%, OR 8,4 (95% ДІ 1,00–70,3) p&lt;0,05). Висновки. Багатосудинне ураження коронарних артерій обумовлює гірший прогноз у пацієнтів із цукровим діабетом. Розвиток повторних порушень кровообігу спостерігається частіше у хворих із порушеним обміном глюкози. Наявність даної патології вірогідно збільшує ризик розвитку інфаркту міокарда, інсульту та хронічної ниркової недостатності.

Aortic Valve Disease and Associated Complex CAD: The Interventional Approach.

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

Multimodal radiological assessment of myocardial viability in patients with ischemic heart disease

Purpose of the study – to determine the radiological indicators of the effectiveness of myocardial revascularization in patients with coronary artery disease. Material and methods. For the implementation of the clinical objectives, 62 patients with ischemic heart disease, heart failure, with preserved systolic function and systolic dysfunction were examined. The patients' age ranged from 40 to 79 years, the average age of the examined was 59.6 ± 8.2 years. 35 (56 %) patients had HF with LV systolic dysfunction with EF of 49 % or less. 27 (44 %) patients had preserved systolic function - ejection fraction greater than or equal to 50 %. Among the studied patients, 5 patients (8.0 %) denied the presence of myocardial infarction. The vast majority of patients (50 patients; 80.7 %) had one myocardial infarction (MI), 7 patients (11.3 %) had two MI. In 5 patients from the group of suffered infarctions, MI without pathological Q wave was recorded anamnestically, and in 52 patients – transmural MI. Results. In the group before treatment, the values of myocardial viability were 69.4 % CI 95 % [65.3 %; 73.5 %], rest-score 18.1 CI 95 % [16.2; 18.0 %], end-diastolic volume (EDV) 147.1 CI 95 % [128; 163.2], systolic thickening of the left ventricle 39.4 CI 95 % [35.9; 43.0], LVEF 40.2 CI 95 % [35.9; 44.6], and after treatment the value of myocardial viability was 75.0% CI 95 % [70.8%; 79.3 %], rest-score 12.5 CI 95 % [10.3; 14.6 %], EDV 132.5 CI 95 % [113.9; 151.1], systolic thickening of the left ventricle 41.4 CI 95% [38; 44.8], LVEF 40.4 CI 95 % [36.5; 44.4]. Conclusion. Thus, the conducted study allowed us to identify functional indicators of the effectiveness of the performed surgical treatment by the method of coronary artery bypass grafting in patients with coronary artery disease. We obtained the registered significance in: myocardial viability (p = 0.0000), end diastolic volume (p = 0.0142) and systolic thickening of the left ventricle (p = 0.0146). Key Words: coronary artery disease, revascularization, myocardial scintigraphy, myocardial viability, coronary artery bypass grafting

Endovascular myocardial revascularization in patients with multivessel coronary artery disease with chronic total occlusion and high surgical risk

The main reason for incomplete myocardial revascularization is the presence of chronic coronary total occlusion (CTO), which is detected in every fourth patient during coronary angiography. At the same time, a generally accepted approach to the treatment of CTO has not yet been developed.Aim. To assess the rationale of complete myocardial revascularization in patients with multivessel coronary artery disease (CAD) with chronic total occlusion and high surgical risk.Material and methods. This retrospective, open-label, non-randomized clinical trial was carried out included 180 patients multivessel CAD and CTO. The patients underwent endovascular surgery for complete myocardial revascularization. Depending on the success of surgery, the patients were divided into groups of complete and incomplete myocardial revascularization. Endpoints were death, acute coronary syndrome, re-revascularization after 1-year follow-up. Left ventricular (LV) contractility and clinical status of patients in the study groups after 1 year of observation was assessed.Results. The median follow-up was 12,1 months. The successful rate of revascularization was 79,4%. The incidence of main composite endpoint in the group of complete myocardial revascularization was 5,59%, while in the group of incomplete revascularizations — 21,6% (p=0,005).Conclusion. The study showed that low incidence of intraoperative complications and a high successful rate of revascularization are characteristic of complete myocardial revascularization in patients at high surgical risk with multivessel CAD and CTO. Complete myocardial revascularization leads to a significant decrease in the incidence of major coronary events.

Complicações da revascularização do miocárdio em pacientes com diabetes mellitus

Este artigo buscou elucidar a relação entre a ocorrência de complicações peri e pós operatórias da cirurgia de revascularização do miocárdio em pacientes portadores de diabetes mellitus (DM). A DM é uma doença de importância mundial, capaz de causar importantes danos ao sistema cardiovascular, aumentando significativamente o risco e a gravidade da doença aterosclerótica. Trata-se de uma revisão de literatura que avalia o prognóstico de pacientes portadores dessa doença crônica submetidos a diferentes métodos cirúrgicos de revascularização miocárdica, associado a outros fatores de risco. Os resultados apontam que pacientes com DM possuem maior risco de pior evolução após a cirurgia, entretanto, esse é um grupo heterogêneo de pacientes, e outras condições como esquema de tratamento hipoglicemiante, etnia, sexo, idade e história clínica, também contribuem para o desfecho. Conclui-se que a abordagem da doença arterial coronariana em portadores de DM depende de uma abordagem individualizada do paciente e de suas comorbidades.

Health Care Analysis on Myocardial Revascularization in Patients with Chronic Coronary Artery Disease: The Multicenter REVASK Study: Design and Protocol.

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are available for revascularization of coronary artery disease (CAD) with the aims to reduce cardiovascular morbidity and mortality and to improve disease-related quality of life in particular. The German National Care Guideline (NVL-cKHK) on chronic CAD recommends the establishment of so-called heart teams for decision making in myocardial revascularization to improve the quality of care. Preferred recommendations for PCI or CABG are given for different patient subgroups depending on patient characteristics, concomitant diseases, and coronary morphology. The myocardial revascularization study (REVASK) is a noninterventional cohort study on care of patients undergoing PCI or CABG based on retrospective statutory health insurance (SHI) routine data, registry data from the German Cardiac Society (DGK) resp., the German Society for Thoracic and Cardiovascular Surgery (DGTHG), combined with prospective primary data collection from health care providers and patients. The primary goal is to investigate whether and to which extent heart teams, consisting of cardiologists and cardiac surgeons, increase guideline adherence in decision making for myocardial revascularization. Ultimately the study project aims to improve patient care in terms of decision making for appropriate myocardial revascularization. Through the consistent implementation of the German National Care Guideline on chronic Coronary Artery Disease (NVL-cKHK) and the European Guidelines on myocardial revascularization, the reduction of morbidity, mortality and the reduced need for subsequent revascularization procedures are also desirable from a health economics perspective.

Levosimendán preoperatorio en cirugía coronaria con disfunción ventricular severa: ¿tiene sentido?

Introduction and objectivesNumerous studies have demonstrated the benefit of levosimendan in patients with chronic and acute heart failure. However, when it comes to its preoperatory use in coronary by-pass surgery in patients with severe ventricular dysfunction, there are some contradictory results. The objective of this study is assessing preconditioning efficiency with levosimendan in surgical myocardial revascularization in patients with severe ventricular dysfunction. MethodsWe design a propensity score-matched cohort study. The study included patients with a LVEF less or equal to 35% who underwent isolated coronary artery by-pass grafting or associated to ischemic/functional mitral surgery from January 2009 to October 2019. They were split into two cohorts whether they received levosimendan preoperatively (Levo) or not (NoLevo); after matching there were 64 patients per cohort. Outcome variables were postoperative morbi-mortality, readmission and follow-up mortality. Statistical analysis: categorical data were compared with a Chi-square or Fisher exact test, and quantitative data with a t-Student or W-Wilcoxon tests. RR/HR were estimated for assessing the association between preoperative use of levosimendan and outcomes. ResultsPreoperative levosimendan use did not decreased in-hospital mortality (RR = 0,86, p = 0.770), and neither do hospital stay, nor postoperative complications. Event-free survival was similar between cohorts in terms of cardiological readmissions, all-cause and cardiological follow-up mortality. ConclusionsOur results do not support the widespread use of levosimendan previously to myocardial revascularization surgery in patients with severe ventricular dysfunction.

Early Results After Coronary Artery Bypass Grafting in Patients With Severe Ischemic Left Ventricular Dysfunction

Introduction. The number of patients with severe ischemic left ventricular dysfunction (ILVD), who undergo coronary artery bypass, increasing each year. ILVD is an established risk factor for mortality in patients after myocardial revascularization during the early and late postoperative periods.Aim of study. To evaluate the early results of surgical myocardial revascularization in patients with coronary artery disease (CAD) and severe ILVD.Material and methods. The study included 149 patients with coronary artery disease with severe left ventricular dysfunction (ejection fraction (EF) ≤39%), operated from January 2002 to December 2018. different variables were assessed (pre- and postoperative), including LV ejection fraction and end systolic volume index (ESVI).Results.The average age of the patients was 59.36±8.97 years (from 30 to 78 years), 93% of the patients were men. In 28 patients (19%), ILVD developed against the background of myocardial infarction (MI) and in 121 (81%) due to ischemic cardiomyopathy (ICMP) with a history of myocardial infarction. The mean EF before surgery was 36.64±3.17 (from 21 to 39%). In the postoperative period, there was an increase in EF, which averaged 44.92±4.92 (from 36 to 59%) (p value &lt;0.001). The mean LV ESVI before surgery was 60.23±11.52 ml/m2. In the immediate postoperative period ESVI decreased to 46.26±12.40 ml/m2(the value of p&lt;0.001). The average number of bypass coronary arteries in one patient was 3.9±0.87. There was also a decrease in the degree of mitral regurgitation in most patients after coronary artery bypass grafting (CABG) (p value &lt;0.001). Hospital mortality was 2% (3 patients).Conclusion. Coronary artery bypass grafting in patients with severe ischemic left ventricular dysfunction can be performed with low mortality. Surgical myocardial revascularization can be considered a safe and effective operation for patients with coronary artery disease with a satisfactory condition of the distal coronary arteries, low ejection fraction, and with a predominance of viable myocardium.

Scintigraphy after Various Methods of Myocardial Revascularization

Abstract. This article presents a comprehensive assessment of the perfusion-functional state of the LV myocardium after direct and indirect revascularization methods at various times after surgery to evaluate the complex relationship between myocardial viability and the method of revascularization. The research shows a significant advantage to using the YurLeon method of inducing extracardial revascularization of the myocardium in patients with diffuse coronary lesions. Aim. Comparative dynamic of scintigraphic indicators with various methods of revascularization. Materials and Methods.The study included 214 patients who underwent myocardial revascularization in various ways. Gated-SPECT was performed before the operation, as well as 1 month, 6 months, 1 year, and 2 or more years after the operation. Results.The groups of patients after CABG and CABG+YurLeon had differences in SRS indicators one year after surgery: 6.58±7.37 (after CABG) and 1.01±1.49 (CABG+YurLeon)(p&lt;0.05).The most significant changes in systolic thickening (WT) occurred in segments with an accumulation of 26-40%: 1.78±1.84 (CABG), 0.51±0.85 (CABG+YurLeon), 2.6±1.19(PCI); and in segments 41-50%: 1.23±1.10 (CABG), 0.14±0.39 (CABG+YurLeon), 2.1±0.8 (PCI) (p&lt;0.05).In the long-term period after revascularization, the total percentage of LV myocardial segments with "functional-perfusion mismatch" stood at: 11.08±11.69% of segments (CABG), 1.26±2.7% (CABG+YurLeon), 18.44±8.70% (PCI) (p&lt;0.05). Conclusion. Comprehensive diagnostics of patients before surgery, including gated-SPECT, allow medical professionals to more effectively choose the method of revascularization and predict the nearest and separated results. Coronary bypass surgery together with the YurLeon technique of indirect myocardial revascularization in patients with severe diffuse lesions of the coronary artery shows more effective results than other methods of surgically treating IHD.

Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry.

The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina. Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression. Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG. Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.

Surgical Myocardial Revascularization in Patients with Severe Left Ventricular Dysfunction: Experience in the Cardiac Surgery Department of the Military Hospital Mohammed V of Rabat

Patients with coronary artery disease associated with severe left ventricular dysfunction, candidates for surgical myocardial revascularization, are with high operative risk. The aim of this study was to assess short and long-term morbidity and mortality and to identify their predictive factors. Methods: We conducted a retrospective study in the cardiac surgery department of the Military Instruction Hospital Mohammed V- Rabat, between 2000 and 2015. The statistical analysis was executed by SPSS. There were 74 patients (mean age 74±10 years, ejection fraction [FE]: 30.07%±4 .5, Euroscore: 6.6±2.9). Results: Hospital mortality was 9.5%, with a follow up time of 59.2 ± 36 months. The survival rate at 10 years was 57%. There was also an improvement in their clinical symptoms and echocardiographic parameters (postoperative FE: 40.36%±11.2). Conclusion: In this group of patients with high operative risk, the long-term results of several studies demonstrate the superiority of surgical treatment on medical treatment.