Postoperative Coronary Angiography Research Articles

Active surveillance for cardiac complications after major noncardiac surgery: implications on resource utilization and safety in high-risk patients

Abstract Background The 2022 ESC guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery recommend that high-risk patients should undergo active surveillance for cardiac complications, including perioperative myocardial infarction/injury (PMI), following major noncardiac surgery. Unfortunately, little is known about the resource use and safety of active surveillance compared to a control cohort (i.e. without active surveillance). Objective To quantify the impact of active surveillance for cardiac complications, by perioperative cardiac troponin (cTn) measurements and a systematic PMI work-up on working days, on resource usage and safety. Methods We did a retrospective comparison of non-randomised pre- vs post-implementation of an active surveillance program for cardiac complications in patients at elevated cardiovascular risk undergoing noncardiac surgery at two hospitals in Switzerland. The two cohorts' resource use and safety were compared. Resource use encompassed perioperative cTn measurements, ECGs, cardiac imaging, cardiology consultations as well as coronary angiography (CAG) and revascularisation procedures. Safety was assessed based on the number of "seemingly normal CAG" and complications arising from CAG and revascularisation procedures. Results A total of 13’147 patients, 10’346 in the active surveillance cohort and 2’805 in the standard-of-care (SOC) cohort, were eligible for this analysis. Patient characteristics between both cohorts were comparable (e.g. median age of 74 vs 73 and 44.8% vs 43% female, respectively). Patients in the active surveillance cohort underwent significantly more perioperative cTn measurements (86.4% vs 3.5%, respectively), postoperative ECGs (13.5% vs 5.7%), postoperative cardiac consultations (5.9% vs 2.4%), postoperative transthoracic echocardiogram (TTE) (7.5% vs 6.1%), postoperative myocardial perfusion imaging (MPI) (1.2% vs 0.6%), and postoperative CAG (0.8% vs 0.4%, all p <0.05). The increased resource use led to a substantial increase in detected cardiac complications within the first 48h after surgery: active surveillance 1’207 (12%) (95%CI 11%-12%) vs SOC 68 (2.4%) (95%CI 1.9%-3.1%). The active surveillance cohort generated an overall cardiac management cost of 236 Euros (95%CI 223–250) per patient vs 133 Euros (95%CI 110–160) per patient in the SOC cohort, resulting in an incremental cost for the active surveillance of 103 Euros (95%CI 110–160) per patient. Thereby the cost of detecting one additional cardiac complication within 48h was 989 Euros. Concerning safety, no significant differences in the number of "seemingly normal CAG" (6.4% vs 15%, p=0.1) and complications due to CAG and revascularisation (0.6% vs 5.1%, p=0.08) were observed. Conclusion The active surveillance for cardiac complications is safe when compared to a standard-of-care cohort while 989 Euros per additional detected cardiac complication seems reasonably priced.Resource-utilization tableOverview

The impact of transcatheter aortic valve replacement on changes of coronary computed tomography-derived fractional flow reserve

Background The effect of transcatheter aortic valve replacement (TAVR) on changes of computed tomography-derived fractional flow reserve (CT-FFR) values was controversial. Thus, we aimed to identify the impact of TAVR on changes of CT-FFR values, plaque characteristics, and the associated clinical impact. Methods This single-center observational study included 39 consecutive patients with severe aortic valve disease undergone TAVR between August 2019 and April 2023, whom were performed with preoperative and postoperative coronary CT angiography (CCTA). The computation of CT-FFR and plaque characteristics was performed by an independent central core laboratory. Results Each patient underwent CCTA and CT-FFR assessment without encountering any complications. Notably, both at discharge and six months post-TAVR, there was a significant improvement observed in the New York Heart Association (NYHA) functional classification, left ventricular fractional shortening, and ejection fraction compared to pre-operative levels. The CT-FFR for left anterior descending artery (LAD), left anterior descending artery (LCX), and right coronary artery (RCA) had no obvious change at discharge compared to pre-operation (0.92 ± 0.05 vs. 0.93 ± 0.05, p = 0.109; 0.96 ± 0.03 vs. 0.95 ± 0.03, p = 0.523; 0.97 ± 0.04 vs. 0.97 ± 0.03, p = 0.533; respectively). Furthermore, TAVR did not exert a significant impact on plaque burden during the perioperative period. Conclusions Our report suggested that TAVR did not significantly affect coronary CT-FFR measurements and plaque characteristics in the perioperative period, and furthermore, the patients’ cardiac function showed gradual improvement in the short-term following discharge.

Vasa vasorum of the no-touch saphenous vein graft observed using frequency-domain optical coherence tomography.

One possible reason for the long-term patency of no-touch saphenous vein grafts is the preservation of the vasa vasorum in the adventitia/perivascular adipose tissue. In this study, we investigated the vasa vasorum of the no-touch saphenous vein graft in vivo using frequency-domain optical coherence tomography, performed qualitative and quantitative analyses, and compared them with the conventional saphenous vein graft. A frequency-domain optical coherence tomography study was performed on 14 saphenous vein grafts at the postoperative coronary angiography 1-2 weeks after surgery (no-touch group, n = 9; conventional group, n = 5). Many signal-poor tubular lumen structures that can be recognised in the cross-sectional and longitudinal profiles, which indicates the vasa vasorum, were observed in the adventitial/perivascular adipose tissue layer in the no-touch saphenous vein grafts. In contrast, the vasa vasorum was less abundant in the conventional saphenous vein grafts. The vasa vasorum volume per millimetre of graft in the no- touch group was significantly higher than in the conventional group (0.0020 [0.0017, 0.0043] mm3 and 0.0003 [0.0000, 0.0006] mm3, P = 0.023). Frequency-domain optical coherence tomography showed abundant vasa vasorum in the thick adventitia/perivascular adipose tissue layer of no-touch saphenous veins in vivo. In contrast, few vasa vasorum was observed in the conventional saphenous vein grafts.

Outcomes of Single versus Sequential Vein Grafts in Isolated Coronary Artery Bypass Surgery: Insights from a Large Tertiary Care Center

BackgroundSaphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited. MethodsBetween 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency. ResultsAt 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22). ConclusionsShort and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG.

Safety assessment of coronary arteries during left bundle branch area pacing.

This study aimed to assess the safety of left bundle branch area pacing (LBBAP) by measuring the distance from the tip of the electrode to the nearby coronary artery with anine-partition grid method. From January 2019 to October 2020, patients who underwent LBBAP and postoperative coronary angiography in the Second Affiliated Hospital of Nanchang University were included in the study. The patients' fluoroscopic images of LBBAP and coronary angiography were collected and analyzed. Changes in the ST‑T segment in the electrocardiogram (ECG), serum troponin, and myocardial enzyme profiles were observed before and after the LBBAP procedure. Atotal of 50patients were included in this study, of whom 46patients underwent implantation with apacemaker and 4patients received an implantable cardioverter defibrillator (ICD). The pacing electrodes were confined to the posterior-middle (PM), median (M), Posterior inferior (PI), and middle inferior (MI) positions of the two-dimensional nine-square grid or in the junction area of the above positions, and were concentrated in the rectangle formed by the line of the center points of the four positions. The average vertical distances from the electrode tip to the left anterior descending branch artery (LAD), posterior descending branches (PD) and the left posterior ventricular branches (PL) were 19.69 ± 8.72 mm, 26.09 ± 8.02 mm, and 21.11 ± 7.86 mm, respectively; the minimum was 5.28 mm, 9.51 mm, and 8.69 mm, respectively. Coronary angiography in all patients showed no significant injury to the ventricular septal branch; however, we observed elevated serum troponin and changes in ST‑T segment in ECG. The study demonstrates that pacing electrodes in LBBAP can be safely implanted over awide range. Coronary arteries are likely to be safe when the pacing electrodes are located within the rectangle formed by the line connecting the PM, M, PI, and MI zone centroids. The left bundle branch can be quickly captured and the safety of the coronary artery can be improved by locating the electrode in the posterior-mid zone. The potential risk of injury to the LAD from the electrode is greater compared with the PD.

Growing Coronary Aneurysm Secondary to Coronary Fistula Despite Decreased Pulmonary Blood Flow/Systemic Blood Flow Ratio in a Child: A Case Report.

Coronary aneurysm secondary to coronary fistula is a rare condition, with no existing report on its pathological examination. We report the case of a patient diagnosed with a right coronary artery fistula with coronary aneurysm during the fetal period. During follow-up after delivery, the aneurysm became larger, even though the shunt size decreased. We were afraid the aneurysm would rupture and therefore, planned elective catheter embolization. At the age of 4 years, the patient underwent surgery, which involved closing the fistula and making the lumen of the aneurysm smaller. However, the surgery was not catheter embolization as planned because segment 3 branched off from the largest aneurysm where we planned to embolize. Pathologically, the structure of the coronary artery differed from that of a healthy one, with thickened intima and media, fewer scattered smooth muscle cells, widely distributed elastic fibers, and mucoid degeneration in the media. The structure of the coronary artery suggested that the vessel wall was weak and that the aneurysm would rupture if not treated. Postoperative coronary angiography showed that segment 2 was obstructed, while the collaterals from the left coronary artery perfused the area. We could have treated the fistula with a catheter as scheduled.

Right coronary artery deformation and injury following tricuspid valve surgery.

Due to its close anatomical proximity to the annular plane of the tricuspid valve (TV), the right coronary artery (RCA) is at risk of injury and distortion during surgical and interventional repair. Recently, reversible, non-flow limiting, purse-string like deformations of the RCA following percutaneous TV annuloplasty have been described. In contrast, there are only anecdotal reports on RCA deformation following conventional TV surgery. A retrospective analysis of all patients undergoing TV surgery in our hospital between 2009 and 2019 was performed including all patients who received a post-operative coronary angiography (POCA). Angiographic footage was reviewed for RCA affections. A total of 1,383 patients underwent TV surgery (replacement and repair) for tricuspid regurgitation in our center. TV repair was performed in 1,248 (90.2%) patients and 135 (9.8%) patients underwent isolated TV surgery. Sixty-five patients (4.7%) underwent POCA within 48 h after surgery due to suspected myocardial ischemia, representing the final study population. Mean age was 70.3 ± 11.3 years, 56.3% were female. Mean EuroSCORE II was 9.8 ± 11.6%. Patients with the need for POCA due to suspected myocardial injury suffered from a higher mortality compared to event-free patients over the long-term follow up period (median 2.9 years) regardless of the observed coronary status. RCA affections were observed in 24 (36.9%) patients. A new RCA deformation without flow-impairment or vascular damage was found in 16 (24.6%) of the cases and was managed conservatively. There was no significantly worse outcome observed as compared to patients without RCA affections. Six (9.2%) patients showed an RCA deformation accompanied by subtotal occlusion. A complete RCA-occlusion was observed in 2 (3.1%) patients. Revascularization by percutaneous coronary intervention could be successfully performed in these patients. RCA deformation occurred exclusively after TV repair while no cases were observed after TV replacement. Right coronary artery deformation without flow-limitation following surgical TV repair is a specific/typical phenomenon which might not impair patients' outcome and could be managed conservatively in most of the cases. RCA injury indicating further interventional therapy is a rare complication of TV surgery. However, the need for immediate POCA in general appears to be associated with a worsened intermediate-term outcome.

Surgical Strategy for Huge Right Coronary Artery Aneurysm Combined with Left Ventricular Fistula

Coronary artery aneurysms combined with left ventricular fistulas are rare; coronary revascularization strategy after coronary artery aneurysm resection is complex in such cases. We report the surgical repair of a giant right coronary artery aneurysm with a fistula in the left ventricle in a 79-year-old woman diagnosed with an aneurysm 50 mm in diameter. Surgical repair included resection of the coronary artery aneurysm, coronary artery bypass grafting to the posterior descending artery, and isolation of reconstructed right coronary circulation from the fistula. The postoperative course was uneventful; postoperative coronary angiography revealed a patent bypass graft unconnected to the left ventricle.

MANAGEMENT OF EARLY GRAFT FAILURE POST CORONARY ARTERY BYPASS GRAFTING: A CASE REPORT

Background: Early postoperative graft failure after coronary artery bypass grafting (CABG) is still a significant problem that results in high morbidity and mortality. It is associated with early graft thrombosis, anastomotic stenosis, bypass kinks, overstretching or tension, significant spasm, and incomplete revascularization. Case Report: 67 years-old male with Coronary Artery Disease involving three vessels (CAD 3VD) underwent CABG surgery. Direct post-operation electrocardiograph (ECG) shown changes in ST segments (elevation on anterior leads and depression on inferior leads) with a significant increase of cardiac markers level. Post-operative coronary angiography revealed an occluded left internal mammary artery (LIMA) graft and native left anterior descending artery (LAD) blockage. Patients’ hemodynamics was not stable, and was urgently underwent an off-pump redo CABG. Intraoperatively we found thrombus at LIMA and saphenous vein graft (SVG) – right coronary artery (RCA) grafts that were caused by atheroma and dissection on anastomotic side. Discussion: The diagnosis of myocardial infarction (MI) remains a clinical challenge since patients are unable to express classic clinical symptoms. Routine ECG combined with cardiac biomarkers are beneficial in diagnosing MI post CABG, and percutaneous coronary angiography (PTCA) is useful in detecting the patency of the grafts. Although percutaneous coronary intervention (PCI) is preferable in the case of anastomosis problem with stable hemodynamic, redo CABG shows more benefit in salvaging infarcted myocardium in patients with unstable hemodynamic. Conclusion: Redo CABG surgery with new or additional grafting may save myocardium and preserve its function in perioperative infarct caused by graft failure.

Minimally invasive coronary artery bypass grafting via a lower ministernotomy for left anterior descending artery myocardial bridging: mid-term results.

Coronary artery bypass grafting or supra-arterial myotomy is now suggested as a better therapeutic option in myocardial bridging (MB) when medical treatment fails to control symptoms. For left anterior descending (LAD) MB, minimally invasive coronary artery bypass via a lower ministernotomy can be offered. Forty-four consecutive patients who underwent elective minimally invasive coronary artery bypass surgery from 2005 to 2014 via an inferior sternotomy using the left internal mammary artery as a bypass graft for LAD MB were evaluated retrospectively. The mean age was 59.1 ± 13.1 years with 26 (59%) men and 18 (41%) women. The mean body mass index was 27.2 ± 3.9 and the mean EuroSCORE II was 1.6 ± 1.8. Routine coronary multislice computed tomography angiography on the 6th postoperative day revealed 97.7% graft patency. During the initial hospital stay, 1 patient (2.3%) underwent a reoperation for early graft failure. Forty patients (91%) could be followed up for a mean period of 64.4 ± 24.5 months after the procedure, during which 2 patients (4.5%) died of non-cardiac causes and 9 patients (20.5%) underwent postoperative coronary angiography with confirmed graft occlusion in only 1 case (2.3%). The improvement in the distribution of patients in the Canadian Cardiovascular Society class 0 was from 4 patients (9%) preoperatively to 37 patients (84%) at the end of the follow-up period (P-value 0.001). Minimally invasive coronary artery bypass surgery via a lower ministernotomy may be safe and efficient for treating LAD artery MB with acceptable complication rates, cosmetic benefits and patency rates.

Bilateral internal thoracic artery grafting in children under 5 years of age with Kawasaki disease: a case series.

BackgroundAlthough persistent coronary artery aneurysm of Kawasaki disease (KD) is rare, some patients develop a life-threatening myocardial infarction. In paediatric coronary artery bypass surgery (PCABS), the internal thoracic artery (ITA) graft is a reliable graft with favourable coronary outcomes. However, few studies have reported the outcomes and technical considerations of PCABS using bilateral ITAs in small children who have multivessel disease.Case summaryWe present the cases of three children under 5 years of age who underwent PCABS utilizing bilateral ITAs. All three patients had known bilateral giant coronary aneurysms associated with KD. Paediatric coronary artery bypass surgery was indicated after confirming multiple coronary lesions with myocardial ischaemia. One child underwent emergency PCABS because of circulatory collapse. The arterial anastomoses were performed under cardioplegic arrest. The left ITA was anastomosed to the left anterior descending artery (LAD) or the circumflex artery. The right ITA was anastomosed to the right coronary artery or the LAD. Post-operative coronary angiography revealed patent bilateral ITA grafts with an excellent run-off in all patients, and none of them have suffered any subsequent coronary event.DiscussionBilateral ITA grafting is a feasible procedure with favourable coronary outcomes for treating small children with multivessel disease, even in the setting of circulatory collapse.

Left Circumflex Artery Injury After Mitral Valve Surgery: An Algorithm Management Proposal

Left circumflex coronary (LCx) artery injury during mitral valve surgery is a life-threatening complication. This report describes a series of patients with this complication in a high-volume mitral surgery center. Between January 2004 and December 2017, a total of 6501 mitral valve procedures were performed at the San Raffaele Scientific Institute in Milan, Italy. An LCx injury occurred in 10 patients (10 of 6501; 0.15%) after either mitral valve repair (n= 5) or replacement (n= 5). Coronary angiography was performed in 9 patients and showed 5 cases of left coronary artery dominance, 2 cases of right dominance, and 2 cases of codominance. All data were prospectively collected in the hospital database and were retrospectively reviewed. Suspicion of LCx injury was raised in the operating room in 5 patients and in the intensive care unit in the other 5 patients. Postoperative coronary angiography confirmed the LCx lesion. In the presence of total LCx occlusion, coronary artery bypass grafting (n= 3) or partial removal of the annuloplasty ring(n= 1) was performed. In cases of partial kinking (n= 4), percutaneous coronary intervention (PCI) was preferred. In the 2 patients with extrinsic subocclusion of the LCx, rescue PCI was initially attempted, but both procedures were complicated by artery disruption and stent underexpansion. In our series, LCx occlusion occurred more commonly in patients with left-dominant coronary artery circulation. Clinical presentation may be variable. Rescue PCI is a valid option in cases of kinking of the artery, but in other cases emergency coronary bypass grafting should be the first choice. Repositioning of the prosthesis may be an option in specific circumstances.

Acute kidney injury following coronary artery bypass grafting and control angiography: a comprehensive analysis of 221 patients.

Postoperative coronary angiography offers the basis for prompt management of ischemic complications after coronary artery bypass grafting (CABG). Little is known about the effects of postoperative angiography on renal function. The current study aims to assess the incidence and risk factors for acute kidney injury (AKI) following postoperative coronary angiography. A total of 221 CABG patients (mean age, 67 ± 8years) underwent postoperative coronary angiography due to perioperative myocardial infarction (PMI). AKI was defined according to the KDIGO criteria. Logistic regression analyses were performed to find out risk factors responsible for AKI and to ascertain significant associations between AKI and in-hospital death. Mean delay from CABG operation to postoperative angiography was 1.4 ± 1.0days. AKI occurred in 79/221 (36%) patients. Mean serum-creatinine (sCr) values peaked on the first day after the angiography and reached the lowest level at the fourth day. In the multivariable analysis, the following variables were independent predictors for AKI: postoperative peak values of CK-MB (p = 0.049, OR 1.03, 95% CI 1.00-1.06 per 10 U/l), EuroSCORE I (p = 0.011, OR 1.18, 95% CI 1.04-1.35), and AKI before re-angiography (p = 0.004, OR 3.50, 95% CI 1.51-8.16), whereas a delayed angiography (p = 0.031, OR 0.69, 95% CI 0.49-0.97) was protective against AKI. Patients with post-angiography AKI had a significantly higher mortality after multivariable adjustment than patients without AKI (15.5% vs. 2.11%, p = 0.001, OR 5.42, 95% CI 1.35-21.75). Over one-third of patients who undergo postoperatively angiography develop AKI. The occurrence of AKI must be considered during the decision-making prior to coronary angiography, especially in patients presenting the identified risk factors for AKI.

Risk of perioperative coronary stent stenosis or occlusion in patients with previous percutaneous coronary intervention undergoing coronary artery bypass grafting surgery.

There is an ongoing discussion about how to treat coronary stents during bypass surgery: Should patent stents be left alone and the stented vessels be ungrafted, or should every stented coronary artery receive a bypass graft? This study aims to determine the relevance of perioperative stent stenosis or occlusion on postoperative outcomes up to 3 years postoperatively. Patients undergoing coronary artery bypass grafting surgery (CABG) (±concomitant procedures) with previous percutaneous coronary intervention from 4 centres were prospectively included in this observatory study between April 2015 and June 2017. A coronary angiography was conducted between the fifth and seventh postoperative days. The preoperative and postoperative angiograms were assessed in a core laboratory, assessing the patencies of coronary stents and bypass grafts. The core lab investigators were blinded to the patients' characteristics and perioperative course. A total of 107 patients were included in the study. In the postoperative coronary angiography, 265 bypass grafts and 189 coronary stents were examined angiographically. Ninety-seven percent of preoperatively patent stents remained patent. New coronary stent stenoses were observed in 5 patients (4.7%). All 5 patients were asymptomatic and managed conservatively. Bypass stenoses were observed in 12 patients (11%), of whom were managed conservatively, 4 underwent percutaneous coronary intervention and 1 underwent redo-CABG. Two years postoperatively, 97% of patients were alive. Patients with new stent stenosis tended to have a better survival compared with patients with bypass stenosis (100% vs 73%; P = 0.09) up to 3 years postoperatively. Perioperative coronary stent stenosis occurs rarely. It is safe to leave a patently stented coronary vessel without bypass grafting.

Preoperative Cessation of Both Dual Anti-Platelet Agents Is Safe after 1 Year in Patients Receiving Percutaneous Coronary Intervention

ObjectiveThe aim of this study was to investigate the atherothrombotic and bleeding risk of discontinuing both components of dual antiplatelet therapy (DAPT) before surgery in patients with an intracoronary stent after 1 year.MethodsWe retrospectively enrolled 212 patients who received an evaluation of perioperative cardiac risk and underwent surgery from March 2017 to March 2019. We divided them into 2 groups: the discontinuation of both antiplatelet agents group (DCAP, no use of any antiplatelet agent) and the continuation of at least 1 antiplatelet agent group (CAP). The primary composite endpoint was the occurrence of major adverse cardiovascular events (MACE), including death, angina, postoperative coronary angiography, stroke, and readmission within 30 days postoperatively. The second endpoint was bleeding requiring the transfusion of ≥2 packs of red blood cells (RBCs)ResultA total of 136 patients were enrolled in the study, with 68 in the DCAP group and 68 in the CAP group. The occurrence of MACE did not significantly differ between the groups (25% vs. 17.6%, p=0.295). The incidence of bleeding that required a transfusion was higher in the CAP group (16.2% vs. 30.9%, p=0.044). The postoperative change in hemoglobin levels (−1.9 g/dL vs. −1.8 g/dL, p=0.742), and the number of transfused packs of RBCs (3.5 vs. 5.3, p=0.347) were not significantly different between the groups.ConclusionPreoperative discontinuation of DAPT did not increase the risk of MACE. However, continuation of at least 1 antiplatelet agent increased the incidence of bleeding requiring RBC transfusion. Further research with a large cohort is warranted.

Direct postoperative invasive coronary angiography after mitral valve repair revealing an iatrogenic total occlusion of the proximal RCx

Direct postoperative invasive coronary angiography after mitral valve repair revealing an iatrogenic total occlusion of the proximal RCx

Incidental Pulmonary Embolism After Coronary Artery Bypass Surgery: Long-Term Clinical Follow-Up

The purpose of this study was to investigate the incidence and natural history of incidentally found and untreated pulmonary embolism (PE) at coronary CT angiography after coronary artery bypass grafting. We retrospectively reviewed the records of 353 patients consecutively registered between January 1, 2010, and November 11, 2015, who underwent coronary artery bypass grafting followed within 2 weeks by coronary CT angiography. All patients received 100 mg of aspirin and 75 mg of clopidogrel after surgery. We collected relevant clinical and CT data, including total follow-up duration after coronary artery bypass grafting, follow-up CT findings, mortality, and incidence of any recurrent PE. PE was diagnosed in 22 of the 353 patients (6.2%) who remained in the study after the exclusion criteria were applied. Most of the PEs occurred at the segmental or subsegmental level. All patients were in hemodynamically stable condition, had no symptoms, and underwent follow-up for a median of 53 months (range 19-74 months). Twenty of the 22 patients did not receive anticoagulation, and all but one of these patients had complete resolution of PE at second follow-up coronary CT angiography (median, 149 days after surgery). There was no associated mortality or recurrent PE. Incidental PE after coronary artery bypass grafting is found in approximately 6% of patients undergoing postoperative coronary CT angiography, and most PEs resolve spontaneously without anticoagulation. No patient in this study died or had recurrent PE during a median follow-up period of 53 months.

Coronary Artery Bypass Surgery in Diffuse Advanced Coronary Artery Disease: 1-Year Clinical and Angiographic Results

Proper treatment of patients with diffuse, severe coronary artery disease (CAD) is a challenge due to its complexity. Thus, data on the outcomes after coronary artery bypass graft (CABG) in this population is scarce. In this study, we aimed to determine the impact of CABG on the clinical and functional status, as well as graft patency in those individuals. Patients with severe and diffuse CAD who underwent incomplete CABG due to complex anatomy or extensive distal coronary involvement were evaluated preoperatively and 1 year after surgery. Postoperative coronary angiography was performed to evaluate graft patency. Graft occlusion was defined as the complete absence of opacification of the target vessel. Stratified analysis of graft occlusion was performed by graft type and territories, defined as left anterior descending artery (LAD), the left circumflex branch, and the right coronary artery territories; the latter two, grouped, were further classified as non-LAD territory. A total of 57 patients were included, in whom 131 grafts were placed. There was a significant improvement in Canadian Cardiovascular Society angina symptom severity (Z = -6.1; p < 0.001) and maximum oxygen uptake (p < 0.001), with a corresponding decrease in the use of long-acting nitrates (p < 0.001). The overall graft occlusion rate was 19.1%, with no significant difference between LAD and non-LAD territories (p = 0.08). However, a significantly lower occlusion rate was noted for the internal mammary artery (IMA) grafts when compared with saphenous vein grafts (p = 0.01), though this difference was only significant in the LAD territory (p = 0.04). Overall, the use of venous graft was the only predictor occlusion at 1 year (odds ratio: 4.03; p = 0.016). In patients with diffuse CAD, incomplete CABG surgery resulted in a significant clinical improvement, with acceptable graft occlusion rates at 1 year, particularly for IMA grafts to the LAD territory.

Efficacy of arsenic trioxide drug-eluting stents in the treatment of coronary heart disease.

The aim of the current study was to evaluate the safety and clinical efficacy of arsenic trioxide drug-eluting (AVI) stents, manufactured in China, for the treatment of coronary heart disease (CHD). Between January and August 2014, 40 patients with CHD admitted to Yongchuan Hospital with implanted AVI stents alone were selected. A one-year clinical follow-up was completed and one year postoperative coronary angiography was reviewed. Major adverse cardiovascular events (MACE), recurrent angina, stent restenosis and stent thrombosis cases were detected. All 40 patients with CHD completed the one-year clinical follow-up, as well as the one-year postoperative coronary angiography. The follow-up results indicated that the MACE rate was 15.0% (6/40), the target lesion revascularization rate was 15.0% (6/40), the angina recurrence rate was 32.5% (13/40), the in-stent restenosis rate was 20.0% (8/40) and the stent thrombosis rate was zero. There were no cases of cardiac death or nonfatal myocardial infarction. The incidence of restenosis was higher following implantation of the AVI stent and the safety and clinical efficacy were worse than expected.

Side-to-side Anastomosis Technique using Four Interrupted Sutures for Sequential Grafting with an Arterial Graft

Objective: Sequential grafting using an arterial graft is essential for achieving complete revascularization and long-term patency with complex multivessel diseases; however, technical difficulties still exist. Side-to-side anastomosis using 4 interrupted sutures for sequential grafting is effective for implementing complete revascularization for such complex coronary lesions. In this study, we evaluated the effectiveness of this technique for small coronary arteries using arterial grafts. Materials and methods: Between March 2010 and March 2017, the side-to-side technique with 4 interrupted sutures and arterial grafts for targeting small coronary arteries, smaller than 1.0 mm in diameter, was performed for 72 sequential anastomoses (69 for proximal touchdown site of sequential graft and 3 for distal) in 68 patients (57 men and 11 women; mean age, 64.4 ± 9.0 years). Results: This technique was frequently used for the proximal portion of the left internal thoracic artery (LITA)-diagonal branch(D)-left anterior descending coronary artery (35 anastomoses; 49%), LITA-D/circumflex coronary artery (Cx)-Cx (19 anastomoses; 26%) sequential grafting. Postoperative coronary angiography was performed for 65 of 72 anastomoses (90%). Fitz-Gibbon grade A was found for 64 of 65 (98%), grade B was found for 1 of 65 (2%), and grade O was not observed. Conclusion: The side-to-side anastomosis technique with 4 interrupted sutures and arterial grafts for small coronary arteries is versatile, safe, and associated with excellent short-term outcomes.